Principles  of  Surgery^ 


W.    A.    BRYAN,    A.  M.,    M.  D. 


PROFESSOR  OF    SURGERY    AND    CLINICAL    SURGERY    AT   VANDF.RBILT   UNIVERSITY, 
NASHVILLE,    TENNESSEE 


ORIGINAL    ILLUSTRATIONS 


PHILADELPHIA  AND  LONDON 

W.    B.    SAUNDERS    COMPANY 
1913 


WO 

J°|l 

IVI3 


Copyright,  1913,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 

PRESS    OF 

W.     B.     SAUNDERS     COMPANY 
PHILADELPHIA      ' 


TO 
THE   MEN    1    HAVE   TAUGHT 


PREFACE 


THE  purpose  in  writing  this  book  has  been  to  put  the  funda- 
mental facts  before  the  student  and  the  physician  in  a  simple 
and  logical  way,  and  thereby  to  lay  a  foundation  upon  which  an 
intelligent  understanding  of  the  immense  details  of  practical  work 
may  be  built.  While  the  title  of  the  book  is  "Principles  of 
Surgery,"  its  real  significance  would  possibly  be  more  correctly 
expressed  by  the  single  word  "Principles";  for  while  the  text 
l>n  -rnts  the  facts  upon  which  surgical  diagnosis  and  treatment 
rest,  it  at  the  same  time  covers  elemental  teachings  which  as 
surely  concern  every  other  branch  of  medical  practice,  especially 
inasmuch  as  the  majority  of  surgical  cases  must  come  at  first 
into  tin-  hands  of  the  practitioner  of  medicine. 

I  desire  to  express  my  especial  thanks  to  Dr.  William  M. 
McCabe  for  permission  to  make  illustrations  from  the  cases  in 
the  Nashville  City  Hospital,  to  Dr.  James  Ewing  who  placed  at 
my  disposal  the  Pathological  Department  of  Cornell  University, 
ami  to  Dr.  Herman  Spitz  for  making  microphotographs. 

W.  A.  BRYAN. 

N  \-IIVII.I.K,  TK. \\Ksan, 
November,  1913. 

11 


CONTENTS 


CHAPTER  I 

SURGICAL  BACTERIA 17 

Protective  Chemic  Powers,  36. 

CHAPTER  II 
ASEPSIS  AND  ANTISEPSIS 47 

CHAPTER  III 

THE  PROCESS  OF  HEALING 66 

Skin-grafting,  79 — Bone-grafting  or  Transplantation,  88. 

CHAPTER  IV 
INFLAMMATION 91 

CHAPTER  V 

SUPPURATION 140 

Pus  Absorption,  143 — Abscess,  145. 

CHAPTER  VI 

SEPSIS 165 

Septic  Intoxication  (Sapremia),  165 — Septicemia  or  Septic  Infection, 
169— Pyemia,  175. 

CHAPTER  VII 
GANGRENE 179 

CHAPTER  VIII 

ULCER 200 

\ 

CHAPTER  IX 
SINUS  AND  FISTULA 218 

CHA1TKU    X 
I.m-ii'ELAS 226 

CHAPTER    M 

NUS,  LOCKJAW 237 

13 


14  CONTENTS 

CHAPTER  XII  PAQB 

RABIES,  LYSSA,  HYDROPHOBIA 249 

Rabies  in  Dog,  251 — Hydrophobia  in  Man,  252. 

CHAPTER  XIII 

ANTHRAX,  WOOL-SORTERS'  DISEASE,  MALIGNANT  PUSTULE,  CHARBON.  .  257 

CHAPTER  XIV 
GLANDERS,  FARCY,  EQUINIA,  MALLEUS 262 

CHAPTER  XV 

ACTINOMYCOSIS 268 

CHAPTER  XVI 

TUBERCULOSIS 274 

Tuberculosis  of  Serous  Cavities,  283 — Tuberculosis  of  Bone  and 
Cartilage,  288 — Tuberculosis  of  Joints,  292 — Tuberculosis  of 
Fascia,  296 — Tuberculosis  of  Kidneys,  296 — Tuberculosis  of  Tes- 
ticles, 298 — General  Symptoms  of  Tuberculosis,  299 — Prognosis 
of  Tuberculosis,  301 — Treatment  of  Tuberculosis,  301. 

CHAPTER  XVII 
SYPHILIS 310 

CHAPTER  XVIII 
BLASTOMYCOSIS 334 

CHAPTER  XIX 

SPOROTRICHOSIS 337 

CHAPTER  XX 
HEMORRHAGE 340 

CHAPTER  XXI 

SHOCK 349 

t 

CHAPTER  XXII 
WOUNDS 355 

CHAPTER  XXIII 
BURNS 371 

CHAPTER  XXIV 

FROST-BITE,  FREEZING,  AND  CHILBLAINS  .  .  .  378 


CONTENTS  15 

( -HAITI:!:  xxv  PAOB 

FRACTURES 382 

CHAPTER  XXVI 

LUXATIONS  OR  DISLOCATIONS 394 

CHAPTER  XXVII 

THROMBOSIS  AND  EMBOLISM 398 

Thrombosis,  398 — Embolism,  403. 

CHAPTER  XXVIII 

ANKIRVSM 412 

CHAPTER  XXIX 
VARICOSE  VEINS,  VARICES,  PHLEBECTASIA 424 

CHAPTER  XXX 

LY.MI-H  \M;IECTASIS  AND  LYMPH-EDEMA 428 

CHAPTER  XXXI 

Ki.KruANTiASis,  ACQUIRED  PACIIVDKHMIA 430 

Rhinophyma,  433. 

CHAPTER   XXXII 

AM. -TI 1 1 ;<IA 434 

CHAPTER  XXXIII 
TUMORS 443 

CHAPTER  XXXIV 

CHONDROMA 453 

CHAPTER  XXXV 

MA 459 

CHAPTER  XXXVI 
MVXOMA 462 

CHAPTER  XXXVII 

Fll«H()MAT\       FIBROIDS) 465 

Special  Forms  of  Fibromata,  470. 

CHAPTEH    \\.\vill 
LIPOMA..  1> 


16  CONTENTS 

CHAPTER  XXXIX                           ,  PAQI! 

ANGIOMA  (HEMANGIOMA) 483 

CHAPTER  XL 

LYMPHANGIOMA 490 

CHAPTER  XLI 
MYOMATA 494 

CHAPTER  XLII 

NEUROMA 499 

Glioma,  500. 

CHAPTER  XLIII 
SARCOMA 502 

CHAPTER  XLIV 
BENIGN  EPIBLASTIC  AND  HYPOBLASTIC  TUMORS,  PAPILLOMA 561 

CHAPTER  XLV 

ADENOMA 565 

CHAPTER  XLVI 
CANCER 572 

CHAPTER  XLVII 
CYSTS 631 

INDEX . .  .  657 


PRINCIPLES  OF  SURGERY 


CHAPTER  I 
SURGICAL  BACTERIA 

BACTERIA  are  microscopic  unicellular  organisms  belonging  to 
the  vegetable  kingdom.  They  are  also  known  as  germs,  microbes, 
or  micro-organisms:  the  last  name  embraces  also  the  microscopic 
organisms  belonging  to  the  animal  kingdom,  known  as  protozoa, 
and  has,  therefore,  a  wider  application,  while  the  first  three  syno- 
nyms given  apply  distinctly  to  those  micro-organisms  embraced 
iu  tlif  definition. 

It  belongs  to  bacteriology  to  distinguish  one  species  of  bacteria 
from  another,  yet  this  distinction  so  closely  concerns  the  surgeon 
in  a  practical  way  that  the  means  of  distinction  are  given  here. 
They  are  differentiated  by  possessing  different  groups  of  charac- 
teristics. 

Shape. — The  appearance  of  bacteria  is  very  variable  for  different 
species,  although  this,  by  no  means,  is  sufficient  of  itself  for  the 
classification  of  any  single  species.  One  shape  frequently  seen  is 
spheric,  another  elongated  or  rod-like;  of  the  former,  some  are 
apparently  flattened  on  the  surface,  as  if  a  segment  had  been  re- 
moved from  it.  while  the  latter  may  be  straight  or  curved,  with  the 
end-  either  rounded  or  square.  Still  others  are  spiral  in  shape, 
and  are  more  elongated  than  the  rod-shaped  germs. 

Arrangement. — As  seen  under  the  microscope,  certain  bacteria 
show  no  tendency  to  group  themselves  after  a  definite  fashion,  and 
others  are  observed  habitually  to  form  such  grouping  as  to  classify 
them  instantly  with  a  small  number  of  species  pos-e— inir  this  trait. 
The  arrangement  is  in  pairs,  chains,  or  bunches,  the  latter  being 
usually  illustrated  by  comparison  to  a  bunch  of  grapes.  In  all 
these  three  forms  of  arrangement  there  is  no  necessary  connection 
I.etween  the  associated  germs — it  results  from  their  habit  of  growth 
and  >o  it  is  usual  to  find  many  individuals  on  the  slide  showing 
no  such  grouping. 

Size.— The  size  of  bacteria  is  more  variable  than  their  shape. 
Some  are  easily  discovered  with  a  one-sixth  lens,  while  other  known 
organisms  require  the  most  delicate  staining  to  be  seen  with  the 
2  17 


18  PRINCIPLES   OF   SURGERY 

most  powerful  microscope  under  the  most  favorable  circumstances; 
there  are  possibly  ultramicroscopic  bacteria  of  which  we  have  no 
knowledge. 

Motion. — There  are  many  species  that  have  the  power  of 
motion,  and  thus  the  ability  to  convey  themselves  in  their  medium 
from  one  point  to  another.  Such  motion  is  accomplished  by  means 
of  very  delicate  processes  from  their  surface,  which,  by  a  kind  of 
ciliary  movement,  are  able  to  drive  the  germs  about  through  the 
medium.  These  cilia,  or  flagella,  may  be  few,  or  so  numerous  as  to 
give  a  distinctly  hairy  appearance,  as  seen  in  some  of  the  non- 
surgical  bacteria;  the  cilia  are  situated  either  on  the  ends  or  sides 
of  the  bacteria,  and  are  rarely  seen  except  on  the  rod-shaped  or 
spiral  varieties,  although  some  of  the  cocci  have  them.  The  pres- 
ence of  flagella  is  no  assurance  that  the  germs  possessing  them  are 
motile.  This  phenomenon  of  motility  is  made  of  service  in  the 
diagnosis  of  disease,  as  illustrated  by  the  clumping  of  bacteria  in 
Widal's  test  for  typhoid  bacilli.  Another  motion,  not  physiologic, 
as  that  just  described,  but  physical,  is  seen  in  small  non-motile 
bodies.  They  dance  around  in  a  minute  orbit  without  being 
removed  from  their  immediate  situation,  and  the  motion  depends 
for  its  causation  on  purely  outside  influences  of  a  physical  or  a 
physicochemic  nature.  It  is  known  as  Brownian  movement. 

Color. — Pigments  are  produced  by  a  few  surgical  bacteria;  the 
greater  number  of  color  producers,  however,  belong  to  the  non- 
pathogenic  group.  Bacillus  pyocyaneus  produces  a  greenish-blue 
pigment,  soluble  in  the  medium  in  which  it  grows,  and  made  up 
of  two  distinct  pigments,  a  blue  and  a  green,  either  of  which  may  be 
produced  at  will  and  the  other  excluded,  by  alteration  of  the 
medium;  Staphylococcus  aureus  and  citreus  produce  an  orange- 
and  a  lemon-colored  pigment  respectively,  hence  their  names. 
The  pigments  are  not  found  in  the  germ;  therefore,  they  are  color- 
less; but  it  probably  results  from  the  combination  of  by-products  of 
the  micro-organisms  either  with -elements  of  the  medium  or  of  the 
atmosphere. 

Mode  of  Growth. — Numerous  factors  are  embraced  under  this 
caption.  The  medium  favorable  to  the  development  of  one  micro- 
organism may  be  positively  refused  by  another.  One  germ  grows 
on  the  surface  of  the  medium,  while  another  grows  only  from  stabs; 
one  liquefies  a  congealed  medium,  another  does  not;  one  grows  only 
in  the  presence  of  oxygen,  another  only  in  its  absence;  one  grows 
into  large,  readily  visible  colonies,  another  into  colonies  so  small 
as  to  be  scarcely  visible;  one  produces  gas  in  its  growth,  another 
none;  one  develops  into  distinct  colonies  in  a  few  hours,  another 
requires  several  weeks  to  manifest  evidence  of  colony  formation; 
one  grows  vigorously  through  comparatively  wide  ranges  of  tern- 


SURGICAL    BACTERIA  19 

perature,  another  must  be  nursed  cautiously  at  a  very  uniform 
temperature  for  good  results. 

Stains. — The  stains  which  are  capable  of  use  in  the  discovery  of 
bacteria  constitute  a  most  important  element  in  their  detection. 
So  valuable  is  this  that  a  large  number  can  be  differentiated  in  a 
practical  manner  by  staining  alone.  The  subject  of  stains  is  so 
long,  and  so  necessary  to  be  learned  in  detail,  that  reference  can 
only  be  made  to  any  standard  work  on  bacteriology.  It  is  only 
necessary  for  the  present  purpose  to  call  attention  to  this  as  one 
of  the  methods  used  iu  differentiation  of  micro-organisms. 

Reproduction. — Bacteria  multiply  with  exceedingly  great  rapid- 
it  y  imder  circumstances  favorable  to  their  growth.  The  average 
time  required  for  a  new  germ  to  develop  into  its  adult  state  and 
produce  other  germs  is  something  near  an  hour.  Some  of  them  may 
pass  completely  through  their  generation  in  as  brief  a  period  as 
twenty  minutes,  others  requiring  a  much  longer  time  than  an  hour. 
So  it  may  be  stated  here  that  it  is  reasonable  to  suppose  some 
micro-organisms  may  produce  disease  in  a  much  briefer  period  of 
time  after  their  entrance  into  the  tissues  of  the  body  than  others. 
As  will  be  seen  later  on,  this  cannot  depend  solely  on  the  rate  of 
reproduction.  The  most  frequent  means  of  reproduction  of  bac- 
teria is  by  fission,  a  process  by  which  the  bacterium  is  converted 
into  more  than  one.  Unlike  the  reproduction  of  higher  orders  of 
organisms,  in  which  the  parent  plant  or  animal  may  deliver  its 
offspring  without  sacrifice  of  parental  identity,  bacteria  lose  their 
identity  in  the  production  of  their  offspring;  they  are  converted 
or  divided  into  new  individuals.  The  usual  number  of  germs 
resulting  from  the  division  of  the  parent  germ  is  two;  when  this  is 
the  case  the  process  is  spoken  of  as  binary  fission,  or  binary  cell- 
division. 

Spores. — Bacteria  may  be  produced  by  spores.  They  do  not 
multiply  by  spore  formation,  for  it  is  highly  probable  that,  when 
circum-iaiu •(•<  arise  under  which  spores  may  be  produced,  many  of 
the  germs  fail  to  produce  them;  it  is  further  true  that  a  single  germ 
usually  produces  only  a  single  spore,  so  that  multiplication  becomes 
an  impossibility.  A  spore  is  the  form  a  germ  assumes  when  cir- 
ei in istances  become  unfavorable  to  the  existence  of  the  germ,  if 
the-r  circumstances  do  not  arise  with  such  rapidity  as  to  preclude 
the  possibility  of  spore  formation.  Spores  are  smaller  than  the 
p-rms  out  of  which  they  come,  they  have  a  denser,  tougher  capsule, 
and  offer  much  greater  resistance  to  destructive  agencies  than  the 
germ.  They  have  no  need  for  t  lie  presence  of  certain  environments 
which  an-  «^>cntial  to  the  life  and  activity  of  the  germ,  except  that 
they  cannot  withstand  intrn-e  heat,  although  they  are  much  more 
n-i-tant  to  this  than  the  p-nns  themselves  are.  The  spore,  there- 


20  PRINCIPLES   OF   SURGERY 

4 

fore,  in  a  way,  assumes  the  same  relation  to  the  germ  that  the 
seed  does  to  the  plant;  in  another  respect  it  is  entirely  different. 
The  seed  of  the  plant  is  developed  for  the  purpose  of  carrying 
the  species  through  seasons  or  circumstances  in  which  the  plant 
could  not  survive;  it  has  no  needs,  and  is  undisturbed  by  such  en- 
vironment; when  the  circumstances  alter  so  as  to  favor  the  growth 
of  the  plant  the  seed  is  converted  into  a  new  plant;  so  far,  the  spore 
is  exactly  similar.  On  the  other  hand,  a  single  plant  produces  many 
seeds  and  multiplication  of  the  species  results;  here  the  spore 
differs;  it  preserves  indefinitely  but  does  not  multiply  the  species. 
Many  bacteria  are  incapable  of  spore  production;  others  produce 
them  only  under  severe  provocation;  still  others  produce  them 
habitually,  even  under  circumstances  favorable  to  flourishing 
growth.  The  tetanus  Bacillus  and  bacillus  anthracis  are  the  chief 
examples  of  habitual  spore  production  among  surgical  bacteria. 

Essential  Life  Conditions. — For  the  proper  development  of 
bacteria,  their  multiplication,  the  elaboration  of  their  poisonous 
by-products,  and  hence  the  production  of  disease,  certain  conditions 
must  be  fulfilled,  without  any  one  of  which  no  harm  can  come. 
The  conditions  necessary  for  the  development  of  all  classes  of  germs 
are  called  essential  life  conditions.  They  are  proper  temperature, 
moisture,  and  nourishment,  or  culture-medium.  The  range  of 
temperature  may  vary  through  several  degrees;  below  this  they 
become  inactive,  although  they  are  not  destroyed  even  by  excessive 
cold;  above  it,  too,  they  become  inactive,  and  if  the  increase  of 
heat  is  sufficient  they  are  killed  thereby.  It  is  a  truism  to  state 
that  germs  capable  of  pathogenic  activity  must  be  able  to  live  and 
multiply  successfully  within  the  ranges  of  temperature  of  the  living 
body.  In  a  completely  dry  state  germs  do  not  multiply,  however 
long  they  may  live;  hence,  moisture  is  necessary;  it  is  present  in  all 
artificial  culture-media,  and  is  abundantly  supplied  in  every  tissue 
of  the  body  subject  to  microbic  invasion.  The  nourishment  of 
germs  is  very  variable,  some  of  them  flourishing  on  a  great  variety 
of  media,  others  fastidiously  accepting  only  one  particular  medium 
and  that  prepared  hi  the  most  accurate  manner.  Pathogenic 
bacteria  must  find  satisfactory  nourishment  in  the  various  tissues 
of  the  body. 

Aerobes  and  Anaerobes. — Aside  from  the  above  conditions,  es- 
sential to  growth  of  all  bacteria,  some  require  additional  factors. 
One  will  grow  in  the  presence  of  oxygen,  and  is,  therefore,  called 
an  aerobic  germ,  or  simply  an  aerobe;  a  second  refuses  to  grow  in  the 
presence  of  oxygen,  and  is  called  an  anaerobic  germ  or  an  anaerobe. 
If  a  germ  will  grow  only  in  the  presence  of  oxygen,  it  is  called  an 
obligate  aerobe.  If  a  germ  grows  only  in  the  absence  of  oxygen, 
it  is  an  obligate  anaerobe.  Most  microbes  grow  in  oxygen  by 


SURGICAL    BACTERIA  21 

preference.  Some  grow  equally  well  with  or  without  it,  and  are 
known  as  optional  or  facultative  anaerobes. 

Considering  the  above-mentioned  requirements,  it  is  easily 
seen  that  if  any  of  these  necessary  conditions  could  be  withheld  in 
practical  work  the  accidents  due  to  infection  would  be  absolutely 
avoidable;  but  the  body  temperature  cannot  be  altered  sufficiently 
to  be  of  value,  and  the  other  two  items  can  be  controlled  only  rela- 
tively, in  so  far  as  it  is  in  the  surgeon's  power  to  limit  the  amount 
of  unnecessary  moisture  and  culture-media  by  the  avoidance  of 
accumulations  of  body  fluids,  and  by  the  removal  of  all  devitalized 
tissues,  on  which  bacteria  can  flourish  with  less  molestation  than 
they  receive  in  living  tissues.  It  is  thus  apparent  why  a  wound 
should  be  as  dry  as  possible  before  it  is  closed,  and  why  the  wound 
that  cannot  be  kept  dry  must  be  drained  to  avoid  accumulation 
of  fluids,  and  why  tissues  that  are  certainly  devitalized  should  be 
removed  instead  of  being  allowed  to  become  separated  by  natural 
processes.  An  additional  weapon  is  offered  the  surgeon  in  dealing 
wit  h  anaerobes,  that  is,  to  secure  the  presence  of  oxygen  in  the  field 
of  infection  by  opening  and  keeping  it  exposed  to  the  atmosphere, 
by  removal  of  accumulations  that  would  prevent  such  exposure,  and 
by  the  employment  of  H2O2,  which  liberates  oxygen. 

Distribution. — Bacteria  are  found  widely  distributed  throughout 
the  earth,  and  no  structure  subject  to  ordinary  atmospheric  and 
climatic  changes  is  without  them.  They  are  more  prevalent  in 
certain  localities  where  filth  is  allowed  to  accumulate  and  decom- 
pose and  where  the  population  is  dense.  They  are,  too,  more 
numerous  in  the  warmer  seasons  of  the  year.  It  is  a  safe  state- 
ment to  assert  that  no  external  object  is  devoid  of  one  or  more  spe- 
GMf.  The  human  body  and  animal  bodies,  aquatic  and  terrestrial, 
are  abundantly  supplied.  The  skin,  the  hair,  the  follicles  of  the 
skin,  the  alimentary  tract,  and  the  genital  tract  of  females  habitu- 
ally contain  great  numbers  of  micro-organisms  of  many  varieties, 
ami  the  urinary  tract  contains  a  few,  although  urine  from  healthy 
individuals  should  contain  few  or  none,  unless  it  be  contaminated 
in  voiding.  The  alimentary  tract  contains  greater  quantities  than 
any  other  part  of  the  body,  a  considerable  proportion  (25  to  30 
per  cent.)  of  the  weight  of  each  motion  being  bacteria.  Cer- 
tain bacteria  infest  certain  parts  of  the  body  with  universal  fre- 
quency, such  as  the  colon  bacillus  in  the  intestine;  others  may  not 
be  universally  distributed,  but  may  appear  constantly  in  the 
cavities  of  certain  individuals;  so  one  may  show  diphtheric  bac- 
teria and  another  the  pneumococcus  as  an  inhabitant  of  tin- 
mouth.  Bacteria  do  not  live  habitually  in  the  tissues  of  the  body; 
all,  except  in  di>ea-r.  are  on  the  skin  surface  or  its  accr— ory 
glands  and  follicle-,  or  on  the  mucous  membrane  and  the  channels 


22  PRINCIPLES   OF   SURGERY 

leading  into  it.  So  practically,  though  the  body  be  covered  and 
lined  with  bacteria,  they  remain  on  or  hi  the  cutaneous  and  mucous 
surfaces. 

It  is  evident  from  the  above  that  it  is  impossible  to  handle 
anything  without  its  becoming  contaminated,  and  impossible  to 
find  anything,  of  itself  not  bactericidal,  that  can  be  trusted  not  to 
be  contaminated.  The  water,  the  food,  the  clothing,  the  dwellings 
of  man,  and  he  himself  are  alike  affected,  none  being  free  from  bac- 
teria. Air — that  is,  dust-free — does  not  contain  germs. 

On  account  of  the  universal  distribution  of  germs  and  their  pres- 
ence on  objects  not  especially  prepared,  it  becomes  impossible  to 
preserve  solutions  free  from  contamination  if  they  are  opened  and 
portions  removed  or  added  from  time  to  time.  Stock  solutions,  as 
kept  in  physicians'  offices  and  in  the  hospitals,  if  made  in  large 
quantities — as  strychnin,  morphin,  atropin,  and  cocain — may  not 
only  accidentally  receive  a  small  number  of  bacteria  from  dust  and 
contact  of  the  stopper  with  unclean  fingers  or  with  objects  on  which 
it  is  laid,  but  these  bacteria  may  multiply  hi  the  solution  until  suffi- 
cient numbers  are  present  to  cause  serious  inflammatory  or  sup- 
purative  processes  consequent  upon  hypodermic  injection. 

Carriers. — Certain  pathogenic  germs  seem  to  be  capable  of 
thriving  only  on  human  tissues,  and  are  unable  to  multiply  outside 
the  body  except  under  the  most  favorable  laboratory  methods. 
Therefore,  it  should  be  possible  to  eradicate  them  from  the  cata- 
logue of  disease  producers.  They  may  live  for  indefinite  periods 
outside  the  body,  but,  unless  replenished  from  diseased  bodies, 
must  ultimately  disappear.  Again,  the  micro-organisms  given 
off  during  confinement  from  disease  may  be  so  dealt  with  as  to 
practically  destroy  them  all.  A  carrier  is  an  infected  individual  able 
and  at  liberty  to  mingle  with  other  people  and  follow  his  vocation, 
who,  though  he  may  or  may  not  show  signs  of  disease,  has  in  his 
body  an  infected  focus  from  which  periodically  or  continually 
the  bacteria  are  given  off.  It  is  known  that  tuberculosis  and  ty- 
phoid fever  depend  almost  entirely  for  their  continuance  upon  di- 
rect or  indirect  transmission  from  the  diseased  to  the  healthy  indi- 
vidual. Individuals  known  to  have  pulmonary  tuberculosis,  tu- 
berculous fistula  in  ano,  or  other  discharging  tuberculous  foci  are 
allowed  to  intermingle  with  others,  and  thus  they  become  carriers 
of  tuberculosis.  It  is  with  especial  reference  to  typhoid  fever  that 
the  term  "carrier"  has  gained  a  place  in  the  nomenclature  of  medical 
literature.  A  typhoid  carrier  is  an  individual  who  has  had  typhoid 
fever  and  recovered  from  it,  but  has  some  structure  of  his  body 
infected  by  the  Bacillus  typhosus  in  pure  or  mixed  culture.  This 
is  usually  the  gall-bladder  or  a  discharging  sinus  leading  to  a  dis- 
eased bone.  The  carrier,  of  necessity,  keeps  his  own  person  con- 


SURGICAL    BACTERIA  23 

laminated  with  typhoid  bacilli  and  distributes  them  wherever  he 
goes,  keeping  the  process  up  for  indefinite  years.  As  many  as 
25  or  30  cases  of  typhoid  fever  have  been  produced  by  a  single  car- 
rier, who  was  a  cook,  and  the  disease  followed  her  from  house  to 
house  with  unerring  certainty.  It  deserves  to  be  emphasized  that 
discharging  surgical  lesions  may  be  distributors  of  infection  as  certainly 
as  those  in  the  bile-passages. 

Classification  of  Bacteria. — Those  bacteria  entering  into  promi- 
nent interest  hi  surgical  work  will  be  given  hi  the  classification. 
Bacteria  are  fundamentally  divided  into  saprophytic,  saprogenic, 
or  non-pathogenic  and  pathogenic. 

A  saprophytic  germ  is  one  that  cannot  live  in  living  tissues, 
whether  it  can  produce  disease  or  not.  If  it  does  produce  disease, 
it  accomplishes  this  by  its  poisons  being  absorbed  into  the  circula- 
tion of  the  blood  or  lymph.  This  is  the  class  of  germs  producing 
decomposition,  and  cannot  invade  the  body  and  attack  living  tis- 
sues. Hence,  whatever  mischief  they  produce  must  be  from  with- 
out. This  group  plays  an  important  part  hi  the  symptomatology  of 
certain  processes,  as  certain  types  of  moist  gangrene  and  sapremia. 
Perhaps  its  most  frequent  representative  in  the  surgical  field  is 
Proteus  vulgaris. 

A  pathogenic  germ  is  one  which  produces  disease  by  living  hi  or 
on  living  tissues.  It  can  invade  the  body  tissues,  gam  a  foothold, 
grow  and  multiply,  and  produce  all  the  types  of  infective  disease. 
Pathogenic  germs  may  also  be  able  to  live  on  dead  or  dying  tissue. 

Pathogenic  bacteria  are  subdivided  into  cocci  and  bacilli.  A 
coccus  is  a  spheric-shaped  minute  germ,  or  one  approximately 
spheric.  A  bacillus  is  a  rod-shaped  germ;  usually  its  length  is 
several  times  its  breadth. 

Cocci  are  subdivided  into  diplococci,  streptococci,  and  staph- 
ylococci. 

Diplococci  are  arranged  in  pairs,  the  chief  surgical  example  of 
which  is  the  diplococcus  of  Neisser,  or  gonococcus,  causative  of 
gonorrhea. 

Streptococci  are  arranged  in  chains  of  varying  length. 

Stuphylococci  are  arranged  in  bunches  or  groups,  often  likened 
to  a  bunch  of  grapes. 

In  the  appearance  of  the  above  three  types  under  the  micro- 
scope tin  ic  is  no  vital  connection  between  the  individuals  entering 
into  a  group,  as  might  be  imagined  from  the  illustrations  used,  and 
isolated  germs  appear  in  the  field  with  no  semblance  of  grouping. 

Then-  are  many  strains  or  varieties  of  streptococci  which  may  be 
embraced  under  two  headings,  namely,  Streptococcus  pyogenes  and 
Streptococcus  ervsipelatus,  from  a  surgical  standpoint.  It  is  not 
certain  that  these  are  different  in  kind,  but  in  degree  of  virulence, 


24  PRINCIPLES   OF   SURGERY 

for  it  is  known  that  certain  cases  of  erysipelas  are  pyogenic,  and 
also  that  streptococci,  in  general,  are  very  variable  in  toxic  power; 
this  variability  can  be  controlled  by  laboratory  methods,  increasing 
or  diminishing  virulence  at  will. 

Streptococci  are  responsible  for  many  disease  conditions,  and 
are  capable  of  exceedingly  varied  activity.  They  are  especially 
prone  to  be  responsible  for  secondary  infections,  of  which  they 
head  the  list.  It  is  estimated  that  they  may  be  recovered  from  the 
heart's  blood  of  one-third  of  all  dead  bodies.  Their  peptogenic 
action  is  less  than  that  of  staphylococci;  hence,  they  do  not  so 
uniformly  produce  suppuration;  however,  the  more  virulent  forms 
may  produce  profuse  suppuration.  Streptococci  represent  one  of 
the  most  dreadful,  if  not  the  very  most  dreadful,  of  the  common 
pathogenic  bacteria,  owing  to  their  virulence,  their  rapid  multi- 
plication, and  their  tendency  to  develop  on  tissues  already  infected 
and  crippled  by  other  bacteria,  and  because  of  the  numerous  acute 
and  chronic  lesions  which  they  may  produce.  They  may  cause 
erysipelas,  septicemia,  pyemia,  the  most  rapidly  fatal  form  of 
peritonitis,  where  they  sometimes  produce  death  within  twenty- 
four  hours  of  their  entrance;  ulcerative  or  malignant  endocarditis, 
impetigo  contagiosa,  streptococcus  pneumonia,  various  inflamma- 
tions of  the  throat  and  tonsils  (e.  g.,  follicular  tonsillitis),  in  which 
latter  they  may  serve  as  a  focal  infection  and  be  responsible  for 
various  general  conditions,  as,  for  example,  acute  or  chronic  arthri- 
tis (rheumatism);  they  are  usually  found  in  Vincent's  angina,  in 
connection  with  the  fusiform  bacillus;  they  are  the  usual  cause  of 
"puerperal  fever."  They  are  frequently  found  as  the  secondary 
infection  in  tubercular  processes,  especially  pulmonary,  and  are 
favorable  to  hemorrhage.  Evidence  is  constantly  accumulating 
that  they  cause  acute  articular  rheumatism.  Recent  investiga- 
tions showed  that  they  were  present  and  the  active  cause  in  a  large 
number  of  cases  of  pruritus  ani  and  vulvae. 

Stapbylococci  are  of  three  varieties,  aureus,  albus,  and  citreus; 
the  first  of  these  is  the  most  prevalent,  and  is  the  common  cause 
of  acute  abscess  and  general  suppurative  conditions.  Staphylo- 
coccus  pyogenes  aureus  produces  a  yellow  pigment  which  is  very 
variable,  being  most  intense  when  the  bacteria  are  grown  upon 
carbohydrate  media.  It  produces  two  toxins,  known  as  staphylo- 
lysin  and  leukocidin.  The  other  forms,  citreus  and  albus,  are  less 
frequently  encountered  than  aureus,  and  are,  except  for  the  color 
produced,  very  closely  allied  to  it,  being,  especially  albus,  probably 
less  virulent.  One  form  of  the  albus  group  deserves  especial 
mention,  namely,  Staphylococcus  epidermidis  albus  of  Welch, 
which  is  found  in  the  deeper  layers  of  the  human  skin,  and  hence  is 
not  removable  by  the  ordinary  practical  methods  of  sterilization; 


SURGICAL    BACTERIA  25 

it  is  often  responsible  for  stitch-hole  abscesses;  it  produces  a  mild 
infection  as  a  rule.  Staphylococci  are  especially  abundant  on  and 
in  the  human  body,  and  are  responsible  for  the  many  secondary 
infections  and  for  most  cases  of  acute  periostitis  and  osteomyelitis. 

Bacilli. — The  common  surgical  bacilli  are  Bacillus  tuberculosis, 
bacillus  of  tetanus,  Bacillus  typhosus,  Bacillus  pyocyaneus,  Bacillus 
pyogenes  fetidus,  colon  bacillus,  Bacillus  anthracis,  Bacillus  mallei, 
bacillus  of  malignant  edema,  Bacillus  aerogenes  capsulatus,  Pfeif- 
fer'-  bacillus,  and  fusiform  bacillus  of  Vincent's  angina. 

Bacillus  tuberculosis  is  not  a  true  pyogenic  organism,  although 
the  caseous  material  resulting  from  its  action  may,  even  in  unmixed 
infection,  disintegrate  into  "tuberculous  pus."  It  occurs  as  the 
sole  causative  factor  in  a  great  number  of  surgical  lesions,  usually 
chronic,  particularly  of  the  bones,  the  lymph-nodes,  and  the  serous 
cavities.  These  by  no  means  exhaust  the  possibilities  of  tubercular 
activity.  This  bacillus,  when  found  in  pure  culture,  produces 
much  less  symptomatic  disturbance  than  when  a  secondary 
pyogenic  infection  is  added,  a  frequent  occurrence  either  from 
accident  or  from  meddlesome  interference. 

The  bacillus  of  tetanus  is  the  typic  spore-producing  germ  as  well 
as  the  typic  surgical  anaerobe.  The  germs  seen  in  a  field  under 
the  microscope  do  not  all  show  spores,  but  a  goodly  number  do, 
giving  them  the  typic  drum-stick  appearance,  owing  to  the 
j  >r« -cnce  of  the  spore  in  the  end  of  the  bacillus.  It  is  not  pyogenic, 
but  may  be  aided  in  its  activity  by  the  presence  of  aerobic  micro- 
orjianisius,  which,  by  their  consumption  of  oxygen,  render  the 
field  more  completely  anaerobic. 

Bacillus  typhosus  is  usually  thought  of  as  belonging  only  to  inter- 
nal medicine.  It  has  been  discovered,  of  recent  years,  with  in- 
creasing frequency  to  be  causative  of  surgical  lesions.  This  is 
much  more  important  now,  in  the  light  of  investigations  of  typhoid- 
carriers,  i  han  eould  have  been  surmised  a  few  years  ago.  Bacillus 
typhosus  becomes  actively  pyogenic  at  times  in  pure  culture,  and, 
\vhcn  attacking  the  osseous  system,  i-  peculiarly  resistant  to  surgi- 
cal methods  applicable  to  similar  lesions  produced  by  other  bac- 
teria. Its  chief  surgical  interest  is  due  to  the  readiness  with  which 
it  attacks  hone  and  the  gall-bladder,  producing  in  the  latter 
cholecystitis  and  ^all-stones. 

Bacillus  pyocyaneus  is  met  with  frequently  in  Mippurative 
wound-.  It  i>  pyouenic.  and  produces  a  bluish-green  pu>:  the  color 
may  be  slightly  manifest  if  the  pus  is  in  a  bulk,  but  shows  itself 
di-iinctly  and  unmistakably  on  the  dre»iims  at  the  edges  of  the 
soiled  area  where  free  access  of  air  is  possible.  By  artificial 
proce->e>  it  i.-  po-sible  to  cause  this  germ  to  produce  only  the  blue 
or  the  green  pigment.  Crown  on  egg-white  the  green  pigment 


26  PRINCIPLES   OF   SURGERY 

appears  with  a  fluorescent  effect,  but  on  a  solution  of  pure  peptone 
only  the  blue  pigment  is  found.  This  bacillus  is  usually  a  second- 
ary infection,  and  is  associated  with  staphylococci  or  streptococci, 
but  it  alone  may  be  the  cause  of  suppuration. 

Colon  bacillus,  or  Bacillus  pyogenes  fetidus,  produces  stinking 
pus.  It  is  not  to  be  considered  the  sole  cause  of  foul-smelling  pus, 
for  a  secondary  saprophytic  infection  may  cause  any  suppurative 
focus  to  have  a  putrefactive  odor.  Bacillus  coli  communis  is 
found  more  frequently  affecting  tissues  in  the  anal  and  perineal 
region,  and  with  great  frequency  in  peritoneal  infections,  especially 
those  due  to  perforations  of  the  appendix,  which  so  often  emit  foul 
odor.  Habitually  within  the  gut,  it  is  potent  with  harm  once  it 
gains  admission  to  the  peritoneal  cavity. 

Bacillus  anthracis,  the  cause  of  malignant  pustule,  is  one  of  the 
largest  bacteria,  and  one  of  the  earliest  recognized  by  the  micro- 
scope by  Pollander  in  1849,  although  its  relation  to  the  disease 
anthrax  was  not  recognized  for  many  years.  It  is  prolific  in  spore 
formation,  and,  unlike  tetanus  bacillus,  does  not  show  increased 
width  at  the  level  of  the  spore.  It  grows  in  chains  very  much  as 
streptococci,  but  the  chains  contain  many  more  individual  bac- 
teria than  the  latter. 

Bacillus  mallei  is  a  non-motile,  aerobic,  slowly  growing  germ 
(on  culture-media).  It  is  not  known  to  be  a  spore  producer,  but 
possibly  is. 

Bacillus  of  malignant  edema  is  a  very  large  anaerobe,  found  under 
similar  conditions  to  tetanus,  and  contaminating  tetanus  cultures 
more  frequently  than  any  other  germ.  It  produces  a  spore  centrally 
and  is  motile.  Like  anthrax,  the  bacilli  grow  end-on  in  chains  of 
great  length.  This  bacterium  does  not  frequently  affect  man, 
although  it  often  attacks  the  lower  animals. 

Bacillus  aerogenes  capsulatus  is  almost  as  large  as  anthrax,  but 
does  not  habitually  grow  hi  chains,  a  very  important  distinctive 
characteristic,  although  at  times  they  are  seen  in  short  chains, 
pairs,  or  clumps.  In  the  tissues  the  bacillus  is  usually  found  to  be 
distinctly  encapsulated.  It  produces  spores  and  is  anaerobic. 
Like  the  Bacillus  mallei  and  bacillus  of  malignant  edema,  it  is 
not  often  encountered  clinically,  but  should  be  recognized  when 
it  is. 

Pfeiffer's  bacillus,  or  Bacillus  influenza,  is  the  accepted  cause  of 
grip,  and  is  found  in  the  secretions  from  the  mouth  and  the  air- 
passages.  It  is  the  cause  of  the  otitis  media  and  meningitis  com- 
plicating grip,  and  is  found  in  certain  acute  and  chronic  respira- 
tory lesions.  It  may  cause  pneumonia,  and  this  is  often  followed 
by  abscess  of  the  lung.  This  bacillus  is  sometimes  recoverable 
from  the  air-passages  or  mouths  of  healthy  people. 


SURGICAL   BACTERIA  27 

Bacillus  fusiformis  is  an  anaerobic  bacillus  which  produces  a 
mouth,  tonsillar,  or  throat  lesion  known  as  Vincent's  angina.  The 
bacillus  is  long,  has  pointed  extremities,  and  is  larger  in  its  middle. 
( 'ultures  of  this  micro-organism  emit  a  foul  odor.  It  is  found  also 
in  noma,  and  is  probably  the  cause  of  this  condition. 


(  Saprophytic 
(  Pathogenic 


(  Diplococci 

Cocci     -j  Streptococci,  several  strains  (  Aureus. 
(.  Staphylococci  •!  Citreus. 

(Albus. 

f  Tetanus,  Anthrax,  Tuberculosis. 
Bacilli  J  Colon,  Typhosus,  Pyocyaneus. 

I  Mallei,     Malignant    edema,    Aerogenes 
I     capsulatus. 

Bacillus    influenza    and     Bacillus    fusi- 
formis. 


Atria  of  Infection. — The  point  of  entrance  of  germs  into  the 
1  xxly  is  known  as  the  atrium  of  infection,  or  simply  the  atrium. 
They  may  gain  access  to  the  tissues  with  or  without  injury  to  the 
tegument.  When  the  latter  occurs  it  is  usually  by  the  mucous 
membrane  of  the  intestine,  and  here  tubercle  bacilli  are  the  chief 
invaders.  The  various  routes  of  infection  are  as  follows: 

(1)  Through  wounds,  the  most  frequent  source  of  general  in- 
fections,   which    under    ordinary    circumstances    are    impotent 
unless  the  epithelium  is  broken.     Fortunately  so;  otherwise  con- 
tinual invasion  would  be  suffered.     The  size  of  the  wound,  its 
depth  and  subsequent  behavior,  may  or  may  not  be  significant  of 
the  presence  or  the  type  of  infection.     Large  wounds  may  be  in- 
fected but  little  and  heal  kindly,  and  in  small  wounds  even  the 
slightest  disruption  of  the  cuticle  may  receive  a  large  amount  of 
virulent   infection  and  result  disastrously.     Superficial  atria  are 
less,  deep  ones  are  more,  favorable  to  anaerobic  infections,  but 
anaerobic  infection  cannot  be  excluded  on  account  of  the  super- 
ficiality  of  the  wound.     Certain  of  the  non-pyogenic  bacteria 
may  gain  admission  through  a  wound,  and,  though  causing  no 
perceptible  interference  with  healing  per  primam,  result  fatally 
before  or  shortly  after  such  healing. 

(2)  Through  the  mucous  membranes  of  the  air-passages  micro- 
orKani-ms  are  admitted  into  the  tissues  so  as  to  produce  disease. 
This  is  much  less  frequent,  so  far  as  the  lining  tissues  of  the  lungs 
are  concerned,  than  was  formerly  thought,  although  there  can  be 
no  doubt  of  direct  infection  of  their  tissues.     It  is  now  established, 
however,  that  much  of  the  pulmonary  infection  observed  is  second- 
ary  to   infections  from  the  alimentary   tract.     The  same  thini: 
may  follow  cervical  lymph-node  infections.     The  tonsils,  pharyn- 
<jeal   and   faucial,   are  frequently   affected   by   infective  processes, 
e-peeially  in  chronic  hypertrophietl  conditions,  by  tubercle  bacilli. 


28  PRINCIPLES   OF   SURGERY 

Secondary  to  these,  the  lymph-nodes,  into  which  drainage  from 
the  primarily  affected  structure  occurs,  become  affected,  and 
after  these  remote  or  general  infection  may  follow,  dependent  upon 
the  virulence  of  the  bacteria  and  the  individual's  resistance.  The 
mucous  membranes  of  the  nose  are  often  the  site  of  ulcers,  small 
wounds,  or  bruises,  and  of  acute  inflammatory  processes,  which 
reduce  the  local  resistance  to  infection  and  render  them,  therefore, 
atria  for  various  bacteria.  So  it  will  be  referred  to  later  that  the 
so-called  idiopathic  facial  erysipelas  is  due  to  entrance  of  strepto- 
cocci through  some  concealed  atrium  in  the  upper  air-passages. 

(3)  The  Alimentary  Tract. — From  the  lips  to  the  external  sphinc- 
ter ani  is  one  continuous  flora  of  infection.  There  are  certain 
species  habitual  in  certain  portions  of  the  tract,  as  the  colon  bacil- 
.lus  in  the  lower  gut;  there  are  certain  additional  species  constant 
in  a  few  individuals,  such  as  Klebs-Loffler  bacilli  or  the  diplococcus 
of  pneumonia,  and  this  tract  is  subject  to  entrance  of  any  of  the 
vast  numbers  of  varieties  of  micro-organisms  contaminating  food 
and  drink,  and  the  great  variety  of  unnecessary  and  unclean  things 
introduced  into  the  mouth  as  a  diversion  or  as  the  result  of  habit. 
So  it  is  evident  that,  unless  tissue  resistance  were  wonderful  and 
eternally  active,  man  must,  of  necessity,  succumb  to  the  micro- 
organic  world.  The  presence  of  particles  of  food  between  the 
teeth  and  around  them,  subject  to  decomposition  in  unclean 
mouths,  increases  the  total  number  greatly;  it  converts  the  mouth 
into  a  very  ideal  culture-tube.  So  it  becomes  patent  how  neces- 
sary it  is  to  cleanse  the  mouth  thoroughly  as  a  preliminary  to 
anesthesia,  since  aspiration  of  such  foul  material  certainly  causes  a 
goodly  percentage,  if  not  the  majority,  of  postanesthetic  pneu- 
monias. This  thorough  cleansing  of  the  mouth  should  be  done  by 
a  competent  dentist,  and  is  imperative  in  cases  which  are  to  be 
subjected  to  gastric  surgery. 

Caries  of  the  teeth  is  another  source  of  infection;  one,  too,  that 
should  not  be  allowed  to  continue  long;  but  among  the  lower  classes, 
the  indifferent,  and  the,  penurious  it  is  so  frequent  as  to  demand 
especial  emphasis.  The  same  observation  made  on  preparation 
of  the  mouth  applies  here.  If,  from  financial  straits,  they  cannot 
have  permanent  dental  work  done,  they  should  at  least  have  tem- 
porary fillings. 

The  mucous  membrane  of  the  intestine  is  no  longer  considered 
able  to  prevent  the  entrance  of  bacteria  with  the  chyle,  even  though 
no  abrasion  be  present.  Tubercle  bacilli  fed  to  healthy  individuals 
gain  entrance  to  the  tissues  by  this  route,  and  many  other  organ- 
isms probably,  but  with  less  frequency. 

It  is  possible  to  prevent  a  large  amount  of  the  mouth  infection 
by  cleanliness  and  carefulness  as  to  the  nature  of  the  food  used. 


SURGICAL    BACTERIA  29 

( '  on  king  does  much  to  prevent  the  entrance  of  pathogenic  bacteria 
into  the  alimentary  tract,  as  also  the  animal  parasites,  such  as 
cy>ticercus  and  trichina.  Most  food  is  cooked,  still  enough 
uncooked  food,  with  water  and  other  fluids  consumed,  is  used  to 
keep  up  a  continuous  reinfection.  These  can  be  sterilized  in  the 
same  way,  as,  indeed,  is  done  voluntarily  or  by  compulsion  in  the 
pre-ence  of  grave  epidemics  so  conveyed.  There  remains  one  item 
w<  >r\  h  mention — the  cook  or  waitress  may,  by  handling  food  care- 
lessly after  cooking,  infect  it  and  convey  disease  that  could  not 
have  been  contracted  from  the  raw  article,  or,  by  handling  dishes, 
infect  them  so  as  to  force  the  disease  upon  the  user,  even  when  every 
specious  precaution  has  been  taken.  Thus  carriers  transmit 
di-ease. 

(4)  The  Genito-urinary  Trad. — Owing  to  the  fact  that  infection 
may  be  introduced  into  the  genito-urinary  tract,  and  may  ascend  or 
<  lr-rrnd,  as  the  case  may  be,  from  one  end  of  it  to  the  other,  attack 
the  various  follicles  and  channels  opening  into  the  chief  passages, 
and  affect  surrounding  tissues  or  become  generalized,  this  is  one 
of  the  chief  locations  of  primary  infections,  which  ultimately  cause 
>rri(  »us  local  or  general  lesions.     The  kidneys  are  among  the  first  hi 
eliminating  bacteria  from  the  body  when  they  have  gained  entrance 
to  the  blood.     Hence,  whatever  the  nature  of  the  infection,  the 
whole  tract  below  must  be  bathed  in  urine  containing  it,  and  may 
at  any  time  be  attacked.     If  there  is  obstruction  to  the  flow  of 
urine,  or  if  residual  urine  be  present  and  decomposition  of  this 
-ta<iiiant  urine  occur,  infection  is  almost  certain.     Again,  the  distal 
end  of  the  passage  is  subject  to  afflictions  peculiar  to  itself,  which, 
when  they  have  once  gamed  entrance,  may  stop  short  of  nothing 
tap  than  the  whole  tract,  extending  from  urethra  to  the  seminal 
\<-irles  or  the  testicles,  or,  in  the  female,  from  vagina  to  uterus, 
from  uterus  to  tubes,  from  tubes  to  peritoneum.     The  urethra 
ami    vagina   habitually   contain   micro-organisms   derived   from 
without,  but  they  do  not  usually  thrive  well,  since  vaginal  secre- 
tions are  antiseptic  and  normal  urine  is  sterile. 

(5)  Placenta. — It  has  long  been  known  that  placental  trans- 
mission of  disease  from  mother  to  fetus  does  occur.     The  most 
prominent  example  of  this  is  found  in  maternal  hereditary  syphilis, 
an  observation  made  hundreds  of  years  before  the  advent  of  bac- 
teriology.    Other  diseases,  especially  medical,  are  well  known  to 
\>c  transmitted  similarly;   for  example,  the  acute  exanthemata, 
children  being  found  with  the  eruption  at  birth  or  a  shorter  time 
thereafter  than  the  period  of  incubation.     Tuberculous  children 
are  also  rarely  found  at  delivery,  and  there  is  no  reason  for  doubting 
that  the  hacilli  may  lie  dormant  in  the  infant  for  variable  periods 
subsequently,   and,   when   circumstances   are   favorable,   assume 


30  PRINCIPLES   OF   SURGERY 

activity.  This  is  likely  a  rare  method  of  conveyance  as  compared 
with  the  usual  external  contagion. 

Elimination  of  Bacteria. — The  question  naturally  arises,  What 
becomes  of  the  bacteria  which  enter  the  body  and  produce  disease, 
particularly  if  the  patient  recovers?  Some  of  them  are  destroyed 
by  the  fluids  and  the  cells  of  the  tissues,  others  are  isolated  by  the 
formation  of  cicatricial  tissue  encysting  the  infected  focus  and 
shutting  off  their  opportunity  to  invade  other  structures,  others 
are  expelled  from  them  by  the  organs  of  elimination  and  secretion. 
The  site  of  the  chief  lesions  determines,  to  some  extent,  the  pre- 
ponderance of  the  work  of  elimination  on  some  one  route;  if  the 
pathology  is  especially  intra-intestinal,  the  majority  will  pass  with 
the  feces;  if  genito-urinary,  then  with  the  urine;  this  is  simply 
an  accident  of  the  performance  of  normal  function.  If  the  bac- 
teria are  in  the  tissues  remote  from  these  passages  or  in  the  blood 
how  are  they  eliminated?  The  answer  may  be  brief,  namely,  by 
the  excretory  and  some  of  the  secretory  organs.  The  urine,  hi 
many  cases  of  general  infection,  demonstrably  contains  the  causa- 
tive bacteria,  as  may  be  shown  by  culture,  inoculation,  or  micro- 
scopic examination,  hi  cases  where  there  is  no  infection  and  has 
been  no  instrumentation  of  the  urinary  passage.  This  is  evinced, 
in  a  clinical  way,  from  the  large  number  of  involved  kidneys  or 
their  pelves  in  the  course  of  general  bacterial  conditions ;  the  same 
method  of  elimination  likely  occurs  more  often  in  localized  processes 
than  our  knowledge  would  warrant  us  in  claiming.  Likewise, 
bacteria  are  recovered  from  the  sweat  of  certain  cases  of  general 
infection.  The  liver  is  another  route  of  elimination,  which,  by 
pouring  the  bacteria  out  with  the  bile,  ultimately  throws  them  into 
the  alimentary  tract.  Many  are  destroyed  in  the  liver.  At  times 
bacteria  are  recoverable  from  the  secretory  glands,  especially  the 
parotid,  and,  in  a  few  instances,  they  may  be  found  in  the  milk. 

Significance  of  Infection. — The  term  "infected"  has  a  dual 
meaning,  depending  on  the  view-point  assumed.  In  the  literal 
sense,  the  view  of  the  bacteriologist,  any  tissue  containing  bacteria 
is  infected.  Since  it  is  probable  that  no  wound  is  made,  accidental 
or  operative,  into  which  a  number  of  bacteria  do  not  enter  from  the 
hands,  from  the  tissue  surfaces,  from  unclean  objects  coming  into 
contact  with  it,  such  as  clothing  or  dressings  applied  by  the  laity,  or 
from  particles  of  dust  in  the  atmosphere;  and  further,  since  most 
wounds  nowadays  show  no  signs  of  infection,  it  is  evident  that  the 
surgeon  means  something  entirely  different  when  he  says  a  wound 
is  not  infected.  It  is  demonstrated  that  in  at  least  the  majority  of 
cases  it  is  impossible  to  sterilize  thoroughly  the  hands  or  the  opera- 
tive field,  and  known  that  in  many  instances  the  operator  is  com- 
pelled to  work  in  a  plainly  infected  field,  yet  without  contamination 


SURGICAL    BACTERIA  31 

of  his  wound.  Absence  of  infection  from  this  view-point  is  used 
in  a  relative  sense,  and  means  that  either  no  bacteria  are  present, 
or,  if  they  be  present,  are  in  quantities  insufficient  to  produce  in- 
flammatory or  other  signs  and  symptoms  and  to  interfere  with 
healing  1>\  first  intention^  So  the  task  of  preparation  of  the  hands 
and  the  field  of  operation  is  confessedly  an  incomplete  work  at  its 
best;  therefore,  every  effort  must  be  used  to  approximate  as  nearly 
as  possible  an  unattainable  ideal.  Infection,  in  this  latter  and 
usual  sense,  means  that  a  dosage  of  bacteria  sufficiently  large  to 
affect  the  tissues  has  been  introduced.  This  dosage  varies  widely 
for  different  bacteria.  Some  of  them  the  tissues  have  little  or  no 
power  to  overcome;  fortunately  they  are  rarely  admitted.  Another 
species  may  be  admitted  in  considerable  numbers,  and  be  destroyed 
without  the  appearance  of  a  blush  of  redness  or  a  drop  of  pus. 
The  degree  of  virulence  or  attenuation  of  the  bacteria  will  deter- 
mine whether  a  given  organism  in  given  quantities  will  produce 
infection.  On  the  other  hand,  the  result  of  the  introduction  of 
bacteria  into  a  wound  is  determined  by  local  and  constitutional 
conditions  present.  The  general  resistance  of  the  patient  may  be 
low,  from  loss  of  blood,  from  disease,  from  exhaustion,  and  he  be 
thus  liable  to  succumb  to  numbers,  which,  if  he  were  normal,  would 
be  disposed  of  in  a  few  hours,  with  no  evidence  of  other  than  a 
sterile  wound.  Locally  the  blood-supply  has  much  weight  in 
determining  the  result.  The  face  and  mouth  often  heal  per  primam, 
even  where  no  effort  at  cleanliness  is  made;  their  blood-supply  is 
good,  whereas  the  joints  are  very  susceptible  to  small  infections 
>ince  they  are  less  abundantly  supplied.  The  anatomic  factors 
are  unavoidable,  and  must  be  accepted  as  they  stand.  Again,  any 
action  or  negligence  on  the  surgeon's  part  that  favors  reduction  of 
tissue  resistance  is  as  culpable,  though  frequently  not  so  patent, 
as  actual  neglect  of  aseptic  technic.  Reference  has  been  made 
already  to  the  removal  of  all  blood-clots,  the  control  of  even  slight 
hemorrhage,  and  the  excision  of  devitalized  tissues.  These  must  be 
done,  and  drainage  must  be  introduced,  if  necessary,  to  avoid  un- 
controllable accumulations  of  lymph  or  blood,  although  drainage 
in  itself  is  not  an  unmixed  good.  Other  things  must  not  be  done 
if  the  best  results  are  to  be  expected.  Non-absorbable  suture  and 
ligature  material,  with  all  due  respect  to  the  great  surgeons  who 
still  use  t  hem,  are  so  much  foreign  substance  in  the  tissues,  and  may, 
months  after  healing,  become  the  site  of  infection  and  result  in 
abscess  and  sinus  or  fistula,  and  necessitate  a  second  operation  for 
their  removal.  It  is  the  consensus  of  opinion  that  non-absorbable 
material  is  harmlo-  in  clean  intra-abdominal  work.  Unnecessary 
traumati>m  to  the  tioues  during  operation.  Mich  as  compression 
of  large  masses  in  clamp-,  tearing,  mangling,  or  Krui-ing.  and  the 


32  PRINCIPLES   OF   SURGERY 

destruction  of  blood-vessels  which  an  accurate  knowledge  of  anat- 
omy would  not  warrant,  all  favor  the  development  of  infection. 
The  ligation  of  masses  of  tissue  with  the  vessels,  the  use  of  unneces- 
sary quantities  of  catgut,  or  ligatures  and  sutures  of  too  large  size, 
and  the  formation  of  unnecessarily  large  knots  in  buried  sutures  or 
ligatures,  all  accomplish  the  same  end.  Catgut  becomes  an  ex- 
cellent culture-medium  when  buried  in  the  tissues,  and  the  knots 
are  often  the  only  remains  to  be  found  in  abscesses  forming  after 
healing  is  accomplished.  Tying  knots  tightly  with  ungloved  hands 
is  likely  to  force  from  the  follicles  of  the  skin  sufficient  bacteria  to 
cause  infection.  Sutures  are  applied  for  the  purpose  of  approxi- 
mating tissues,  but  must  not  constrict  them.  When  tied  tight 
enough  to  shut  off  the  blood  supply,  they  not  only  fail  in  their  pur- 
pose of  obtaining  union,  but  cause  the  tissues  to  die,  and  offer  the 
same  conditions  favorable  to  infection  as  if  lifeless  masses  were  left 
at  the  time  of  operation.  The  use  of  antiseptics  is  often  a  specious 
and  harmful  effort  to  destroy  bacteria  in  wounds;  they  not  only  fail 
often  to  do  so,  but  put  hors  de  combat  the  only  agents  that  can,  and 
leave  the  wound  surfaces  crippled  or  dead,  so  that  they  can  no 
longer  resist  even  infinitestimal  quantities  of  bacteria.  This  may 
all  be  summed  up  in  a  word — whatever  reduces  the  vitality  of 
the  patient  as  a  whole,  or  of  the  part  concerned,  favors  the  devel- 
opment of  bacteria.  Injections  of  pathogenic  germs  into  the 
peritoneal  cavity  are  taken  care  of  by  the  powerful  destructive 
and  absorbent  capacity  of  that  membrane;  the  same  dosage,  in- 
troduced with  a  considerable  quantity  of  water,  produces  fatal 
peritonitis,  due  to  the  consequent  slower  destruction  and  removal 
of  bacteria. 

Manner  of  Producing  Disease. — The  mechanical  presence  of 
bacteria,  so  far  as  it  may  have  weight  in  the  production  of  disease, 
may  be  discarded  as  negligible.  If  pathogenic  bacteria  should  be 
so  enormously  abundant  as  to  block  a  comparatively  few  capil- 
laries, an  unusual  occurrence,  even  then  the  chief  effect  would  be  in 
a  different  direction.  As  bacteria  grow  and  multiply,  they  pro- 
duce and  throw  off  certain  toxic  substances,  which  may  be  called 
excretions  for  want  of  a  more  definite  understanding  of  them,  and 
these  excretions  produce  the  symptoms  growing  out  of  an  infec- 
tion. These  poisons  are  known  as  toxins,  which  are  soluble, 
closely  allied  chemically  to  albumins,  and  very  violent  in  their 
action  on  tissues.  These  poisons  are  liberated  from  the  bacteria 
into  the  tissues  or  the  culture-medium  and  remain  after  nitration 
of  the  medium.  They  are  different  for  different  bacteria,  each 
pathogenic  species  producing  its  own  peculiar  toxin.  Toxins  are 
chemically  unstable,  being  unable  to  resist  higher  temperatures 
than  80°  C.  and  slowly  decomposing  at  from  50°  to  60°  C.  Certain 


SURGICAL   BACTERIA  33 

bacteria  produce  toxins  which  have  the  power  of  disintegrating  or 
<  li»t  >lving  red  blood-cells  (hemolysins).  The  toxins  may  act  locally, 
producing  no  perceptible  constitutional  symptoms,  or  constitu- 
tionally, with  few  or  no  local  signs,  or  they  may  act  in  both  ways 
at  the  same  time.  The  tetanus  bacillus  will  produce  slight  if  any 
local  changes,  and  so  act  on  the  motor  centers  as  to  result  in 
death  in  a  few  days  or  hours,  besides  having  a  hemolytic  influ- 
ence. There  are  contained  within  the  bacterial  cells  poisons  which 
arc  not  thrown  off  from  their  bodies  as  the  toxins  are,  and  cannot 
me  a  part  of  the  culture-media  until  they  are  disintegrated. 
They  are  not  specific,  as  the  toxins  are,  but  are  supposed  to  be 
identical  in  the  various  classes  of  bacteria,  and  are,  for  the  most 
part,  pyogenic.  Hence,  when  an  infection  occurs  the  toxins  act 
locally  and  generally,  while  the  dead  bacteria  that  disintegrate  or 
arc  destroyed  by  leukocytes  may  cause  general  disturbance,  as 
shown  by  the  rise  of  temperature  and  local  inflammatory  or  sup- 
purative  changes.  The  virulence  of  all  toxins  and  endotoxins 
varies  with  different  species  of  bacteria;  one  is  so  intensely  viru- 
lent as  to  be  influenced  by  no  degree  of  resistance  on  the  part 
of  the  tissues,  and  another  so  mild  that  severe  reduction  of  normal 
re-i.-tance  must  be  sustained  before  they  can  gain  a  footing; 
likewise  in  the  same  species  the  virulence  varies  widely;  a  strain 
of  streptococci  from  a  dangerously  infected  patient  is  almost  cer- 
tain to  produce  a  virulent  infection  on  gaming  entrance  to  a  new 
field.  The  same  fact  is  a  matter  of  common  observation;  one 
-erics  of  cases  of  typhoid  will  be  mild,  with  a  low  mortality  and 
few  and  mild  complications;  another  epidemic  violent  in  its  mor- 
tality and  complications. 

Mixed  Infections. — If  a  pure  culture  of  bacteria  gains  entrance 
to  the  tissues  it  produces  an  infection,  simple  or  single  infection. 
If  more  than  one  species  be  present  it  is  called  a  mixed  infection. 
The  bacteria  first  gaining  entrance  constitute  the  primary  infection; 
the  -econd  admitted  constitutes  the  secondary  infection,  and  so  on. 
Hi -i ice,  a  mixed  infection  may  mean  that  two  or  more  species  were 
present  at  the  beginning,  or  that  one  was  present  and  subsequently 
another  superadded.  An  infection  occurring  after  all  bacteria 
pass  from  the  field  is  called  reinfection.  Mixed  infections  are, 
under  certain  circumstances,  capable  of  infinitely  greater  harm 
than  a  single  infection.  The  primary  infection  may  be  of  no  fur- 
ther consequence  than  to  reduce  the  vitality  sufficiently  to  allow 
a  violent  secondary  infection  to  gain  a  footing  and  produce  death. 
The  primary  infection  may  be  aerobic,  and  an  anaerobe  superadded 
may  thrive  in  the  pre-ence  of  the  fir>t  infection,  although  it  could 
not  have  found  the  field  sufficiently  oxygen  free  to  produce  disease 
otherwise.  Tubercular  infections  are  much  more  serious  in  symp- 
3 


34  PRINCIPLES   OF   SURGERY 

tomatology  and  outcome  when  secondary  pyogenic  infections  are 
added.  This  is  especially  true  if  the  secondary  infection  is  strep- 
tococci. The  same  precautions  must,  therefore,  be  taken  to  pre- 
vent secondary  infection  being  engrafted  upon  a  primary  as  would 
be  taken  to  prevent  a  primary  infection. 

Antagonistic  Bacteria. — Of  little  practical  therapeutic  value  as 
yet,  it  remains  an  interesting  fact  that  certain  bacteria  are  mutually 
antagonistic.  Anthrax  and  erysipelas  are  perhaps  the  most  not- 
able examples.  When  both  are  present  in  an  animal  it  stands  a 
better  chance  to  overcome  them  than  when  anthrax  alone  is 
present.  However,  either  may  gain  the  ascendancy  and  produce 
death.  It  is  also  known  that  certain  bacteria  will  not  grow  on  a 
medium  on  which  another  species  has  lived.  Curative  properties 
have  been  observed  in  infections,  especially  with  streptococci. 
Sarcoma  (which  is  not  an  infection)  has,  in  a  small  percentage  of 
cases,  recovered  after  an  attack  of  erysipelas,  and  the  attempt  has 
been  made  to  treat  sarcoma  with  sterilized  cultures  of  streptococci, 
sold  under  the  name  of  Coley's  fluid.  The  favorable  results  have 
been  comparatively  few.  Recently  Schiotz  has  demonstrated  that 
Klebs-Loffler  bacilli  disappear  from  the  throat  of  carriers  of  diph- 
theria if  a  spray  of  living  Staphylococcus  aureus  is  persistently  em- 
Dyed. 

The  Protective  Powers  of  the  Body. — The  ubiquitous  distribu- 
tion of  bacteria,  the  frequent  contact  of  the  body  outside  and  in- 
side with  them,  and  the  numerous  wounds  and  other  lesions  that 
might  serve  as  atria  for  the  entrance  of  infection,  have  been  studied, 
and  force  upon  us  the  conviction  that,  without  a  very  extensive 
resistance  on  the  part  of  tissues,  there  would  be  constantly  present 
in  the  body  some  form  of  infection,  if  indeed  existence  were  at  all 
^  possible. 

\  Epithelial  Protection. — The  surface  of  the  skin  and  mucous 
membrane  is  covered  with  epithelium  which  must  act  as  a  barrier  to 
the  entrance  of  bacteria  into  the  subjacent  tissues,  if  one  considers 
the  rarity  of  infection  while  the  epithelium  remains  intact  and  its 
frequency  when  the  epithelium  is  denuded  or  broken.  These 
epithelial  cells  are  not  favorable  pabulum  for  bacteria,  and,  al- 
though the  hands  may  continually  come  in  contact  with  virulent 
bacteria,  infection  is  very  rare.  When  it  does  occur  it  is  because 
the  follicles  or  glands  of  the  skin  serve  as  points  of  vantage,  as  has 
been  shown  by  the  production  of  furuncles  by  rubbing  pure  cul- 
tures of  Staphylococcus  aureus  on  the  skin.  Bacteria,  therefore, 
may  abound  on  the  surface  of  the  body  or  of  the  mucous  membrane 
and  multiply  without  limit  in  the  contents  of  the  alimentary  tract 
with  no  resultant  harm.  That  the  epithelium  is  a  barrier  to  the 
entrance  of  bacteria  is  sometimes  spoken  of  as  the  law  of  Wysso- 


SURGICAL    BACTERIA  35 

kowickz.  The  mucous  membrane  of  the  intestine  is  not  com- 
pletely amenable  to  this  law;  it  has  been  demonstrated  that  bac- 
teria do  enter  with  the  chyme  into  the  lacteals,  and  thence  escape 
into  the  general  circulation,  even  at  a  time  remote  from  their  pass- 
age through  the  wall  of  the  gut. 

The  Law  of  Metschnikoff. — When  bacteria  gain  entrance  to  the 
tissues  their  spread  would  again  easily  become  universal  unless  they 
were  interfered  with.  As  soon  as  an  insoluble  foreign  poisonous 
substance,  animate  or  inanimate,  gains  admission  to  the  submucous 
or  subcutaneous  tissues,  large  numbers  of  leukocytes  gather  in 
and  around  the  field  invaded,  wall  off  and  isolate  that  field,  and 
l>egin  their  work  of  destruction.  This  is  known  as  the  law  of 
Metschnikoff.  This  is  a  most  efficient  means  of  localizing  infec- 
tion, and  does  not  fail,  except  when  the  bacteria  spread  so  rapidly 
or  are  so  numerous  that  the  leukocytes  cannot  keep  pace,  or  when 
they  are  so  virulent  that  a  negative  chemotaxis  is  present,  or  when 
the  wall  of  leukocytes  is  broken  up  by  extraneous  forces.  It  is, 
therefore,  much  more  difficult  for  bacteria  to  produce  disease  in  a 
healthy  granulating  wound  than  in  a  fresh  one. 

The  Action  of  Lymph-nodes. — The  fluids  going  centrad  in  the 
lymph-vessels  frequently  contain  bacteria;  this  was  shown  above, 
in  the  entrance  of  bacteria  through  the  intestinal  mucous  mem- 
brane, and  occurs  in  the  great  majority  of  infections.  The  lymph- 
nodes  are  abundantly  placed  at  the  most  likely  portals,  and  serve 
as  living  filters  to  all  the  fluids  passing.  Arranged  in  series,  few 
bacteria  can  escape  them  under  normal  conditions.  When  they 
become  overloaded  they  are  rescued  by  the  leukocytes  coming  to 
their  assistance,  as  elsewhere,  or  are  sacrificed  for  the  protection 
of  the  more  essential  tissues.  In  this  way  inflamed  or  suppurative 
lymph-nodes  are  produced. 

Chemotaxis.  Living  cells  have  the  power  of  approaching  and 
attacking  foreign  substances,  animate  or  inanimate,  which  may 
intrude  themselves  into  the  tissues,  or  of  rejecting  them.  This  is 
known  as  chemotactic  power,  and  the  exercise  of  it  is  chemotaxis. 
If  the  cell  (leukocyte)  consumes  the  foreign  body,  the  bacteria, 
chemotaxi-  is  positive;  if  it  refuses  to  do  so,  chemotaxis  is  negative. 
There  is  some  capacity  in  the  leukocytes  especially,  and  in  many 
other  type-  «>t  tissue  cells  less  frequently,  that  enables  them  to 
perform  this  function  of  phagocytosis,  positive  chemotaxis,  or  to 
refuse  to  perform  it,  negative  chemotaxis.  The  cause  underlying 
chemotaxis  is  the  toxicity  of  the  bacteria;  the  greater  their  viru- 
lence, the  less  al>le  the  leukocytes  are  to  attack  them.  By  injecting 
virulent  streptococci  into  the  peritoneal  cavity  of  animals,  and 
sul>-e<|Urntly  examining  the  leukocytes  found  in  the  peritoneal 
fluid,  it  is  learned  that  t'e\v  or  none  of  the  white  cells  contain  l»ae- 


36  PRINCIPLES   OF   SURGERY 

reria  (negative  chemotaxis) ;  on  the  other  hand,  the  injection  of  a 
saprophytic  species,  like  Proteus  vulgaris,  shows  many  bacteria 
in  each  leukocyte  (positive  chemotaxis) .  This  is  known  as  Bordet's 
experiment. 

It  becomes  plain,  from  the  above,  that  this  particular  factor  of 
tissue  resistance  will  be  increased  if,  in  the  first  place,  the  number 
of  leukocytes  can  be  increased  adequately  to  cope  with  the  number 
of  bacteria  in  a  given  infection;  if,  in  the  second  place,  they  can  be 
brought  into  the  field  of  action  in  sufficient  numbers;  if,  in  the  third 
place,  such  dealing  with  the  tissues  may  be  performed  as  to  increase 
their  positive  chemotactic  power,  or,  with  the  bacteria,  as  to  reduce 
their  repulsiveness  to  the  phagocytes. 

PROTECTIVE   CHEMIC  POWERS 

The  chemic  protective  powers  of  the  tissues  are  manifold;  of 
chief  importance  are  alexins,  agglutinins,  antitoxins,  and  opsonins. 
They  will  be  discussed  in  their  order. 

Alexins. — The  names  mycophylaxins  and  mycosozins  are  used 
synonymously.  The  body  fluids,  serum,  lymph,  and  fluids  of  the 
tissues,  as  well  as  many  of  the  secretions,  contain  substances 
which  give  them  a  definitely  bactericidal  or  bacteriolytic  power. 
These  substances,  called  alexins,  must  not  be  associated  with  the 
ordinary  chemic  antiseptics.  The  power  of  the  latter  is  largely 
universal  in  their  application.  The  destructive  powers  of  the  body 
fluids  are  specific  in  that,  when  their  ability  to  destroy  a  special 
bacterium  has  been  exhausted,  they  may  still  have  a  like  capacity 
for  another.  This  power  fluctuates  from  time  to  time,  and  may  be 
reduced  to  a  valueless  minimum  by  exhaustive  infections.  They 
have  the  same  activity  toward  blood-cells  from  another  species 
that  they  have  on  bacteria,  producing  hemolysis  or  hemagglutina- 
tion.  The  alexins  are  capable  (their  complements)  of  attacking 
dead  tissues,  making  traumata  favorable  atria  by  exhaustion  of 
bactericidal  properties.  They  are  the  product  of  white  blood- 
corpuscles,  and  may  be  increased  locally  on  demand,  either  by 
natural  means,  as  in  cases  of  infection,  or  by  artificial  means,  as  in 
irritation  and  Bier's  hyperemia.  A  high  potency  of  blood-serum 
against  a  species  of  bacteria  is  not  proof  against  their  production  of 
disease,  an  example  of  which  is  tjrphoid  fever. 

Agglutinins  belong  to  the  same  category  as  the  alexins,  if,  in- 
deed, they  be  not  different  manifestations  of  the  same  or  closely 
allied  chemic  agents.  Their  power  consists  in  clumping  bacteria 
or  blood-cells  and  destruction  of  motile  power  in  the  former.  They 
are  used  as  a  diagnostic  means  in  Widal's  test  for  typhoid,  but  have 
no  present  therapeutic  value  susceptible  to  our  control. 


SURGICAL    BACTERIA  37 

Antitoxins. — This  term  conveys  its  own  significance  in  a  super- 
ficial way,  but  neither  this  nor  any  other  of  the  chemic  protective 
agencies  of  the  tissues  has  been  worked  out  with  sufficient  con- 
clusiveness  to  cause  all  investigators  to  agree  as  to  the  nature  and 
origin  of  the  agents  producing  the  results.  It  is  settled  in  a  practi- 
cal way  so  that  the  therapeutic  value  of  antitoxins  may  be  under- 
stood. An  antitoxin  is  an  agent  that  has  the  power  to  neutralize 
a  toxin,  without  any  deleterious  action  on  the  bacteria  which  pro- 
duced that  toxin.  It  is  a  something  capable  of  preventing  toxins 
from  acting  on  the  tissues  so  as  to  produce  disease.  Toxins  are 
the  product,  direct  or  indirect,  of  bacteria;  direct,  if  the  poisons  are 
produced  within  the  bacteria;  indirect,  if  there  is  produced  in  the 
bacteria  a  substance  which,  on  liberation,  becomes  chemically 
combined  with  certain  tissue  compounds  so  as  to  result  in  toxins. 
Therefore,  whether  the  antitoxin  combines  with  the  toxins  and  takes 
away  their  toxicity,  or  whether  it  separates  them  into  two  non- 
toxic  segments,  or  acts  on  the  non-toxic  products  of  the  germ,  and 
prevents  its  ultimate  combination  to  produce  toxins,  is  practically 
one  thing  to  the  physician  who  must  cure  disease.  The  antitoxins 
in  common  use  are  in  the  form  of  antitoxic  sera,  chiefly  antidiph- 
theric  serum,  antitetanic  serum,  antistreptococcic  serum,  and  Flex- 
er's  antimeningococcic  serum  (bacteriolytic  rather  than  antitoxic). 
As  the  toxins  are  different  for  different  infections,  so  there  must  be  an 
antitoxin  for  every  species  of  infection;  no  antitoxin  has  curative 
properties  for  other  than  the  species  by  which  it  was  produced.  Anti- 
toxins are  developed  in  the  tissues  in  a  given  infection.  The  quantity 
may  be  small  or  great,  depending  on  the  amount  and  virulence  of  the 
infecting  agent  and  the  ability  of  the  tissues  to  react.  It  may  be 
so  great  that  the  individual,  if  recovering,  remains  for  a  time  at 
least  more  or  less  immune  to  reinfection.  In  other  instances  the 
infection  seems  only  to  render  him  more  susceptible  to  reinfection. 
Antitoxic  sera  are  derived  by  inoculating  animals  (horses,  sheep, 
and  cattle)  with  gradually  increasing  doses  of  pathogenic  bacteria 
until  no  further  reaction  can  be  produced  by  dosage  that  should 
prove  fatal.  The  serum  is  derived  from  the  blood  of  the  animals, 
sterili/ed  at  temperatures  which  will  not  affect  the  antitoxic  prop- 
ert  ies,  and  placed  in  sealed  sterile  tubes.  The  dosage  is  measured 
in  units,  a  unit  being  the  amount  required  to  immunize  a  250-gm. 
guinea-pin  again-t  t  he  minimum  lethal  dose  of  bacteria  which  would 
otherwise  kill  it  in  three  or  four  days. 

Ehrlich's  Side-chain  Theory. — The  exact  manner  in  which  cells 
combine  with  food  molecules,  reaching  them  for  the  maintenance 
of  their  vitality  and  the  performance  of  their  function,  is  not  known. 
Likewise,  it  has  not  been  demonstrate:!  how  toxins  act  on  the  cells 
to  produce  their  deleterious  effect  and  pervert  or  de-troy  the  func- 


38  PRINCIPLES   OF   SURGERY 

tions  of  the  cells  affected.  The  theory  of  Ehrlich,  known  as  the 
side-chain  theory,  proposes  to  explain,  and  does  explain,  with  more 
satisfaction  than  any  so  far  advanced,  the  phenomena  taking  place 
hi  the  case  of  toxic  action.  It  has,  therefore,  become  widely  ac- 
cepted. While  it  may  undergo  alteration  as  further  evidence  is 
gathered  concerning  the  real  chemic  structure  of  cells  and  their 
action  on  their  environs,  still  it  conveys  in  a  tangible  form  the  facts 
of  the  case.  In  order  to  maintain  their  normal  status  of  nutrition 
all  living  cells  must  be  capable  of  taking  to  themselves  and  appro- 
priating certain  food  molecules  from  the  blood,  and  they  must 
be  controlled  in  this  activity  by  some  centralized  power.  Ehrlich 
conceives  the  nucleus  to  be  the  central  directing  part  of  the  cell; 
the  cell  must  have  certain  unsatisfied  points  of  valency  which  are 
ready  to  take  to  themselves  the  substances  flowing  hi  the  blood; 
these  points  of  valency  are  themselves  capable  of  liberation  from 
the  cells  and  of  entering  the  blood  as  very  complex  radicals;  they 
are  called  side-chains,  distinguishing  them  from  the  central  func- 
tionating nucleus.  These  side-chains  vary  for  different  types  of 
cells,  so  that  one  cell  may  appropriate  one  substance  and  another 
something  wholly  different;  that  is,  they  are  selective.  When 
toxins  are  dissolved  in  the  blood  the  side-chains  of  the  cells 
capable  of  combining  with  such  toxins  do  so,  and  make  the  toxin 
molecule  a  part  of  the  cell  just  as  if  it  were  a  food  molecule,  and  so 
that  the  nature  of  the  cell  is  changed  and  a  perverted  function 
arises  or  symptoms  of  toxemia  are  produced.  It  must  be  under- 
stood that  the  toxin  molecule  must  enter  into  the  cell  physically 
and  there  make  its  combination  with  the  receptors,  for  so  the  side- 
chains  are  called.  It  must  further  be  understood  that  this  whole 
process  is  of  purely  a  chemic  nature,  and  that  the  toxin  molecule 
becomes  a  part  of  the  cell  substance,  and  is  often  thereafter  insepa- 
rable from  it.  When  the  receptors  are  all  used  up  in  a  cell,  it  pro- 
ceeds to  produce  more  of  them,  even  in  excess  of  the  demand,  stimu- 
lated by  the  action  of  the  toxin-receptor  combination.  These 
become  liberated  from  the  cell,  pass  out  through  the  cell  wall  and 
into  the  blood,  directly  or  indirectly,  and  there  remain  ready  to 
become  united  with  the  specific  toxin  molecule  which  has  caused 
their  overproduction  and  liberation,  but  with  no  other.  Antitoxins 
are  the  free  receptors  in  the  blood  or  serum  ready  to  combine  with 
toxin  molecules.  When  combined,  they  behave  as  inert  bodies, 
having  completely  neutralized  the  toxin  molecules.  Adami  thinks 
that  a  single  toxin  molecule  within  a  cell  may  serve  to  liberate 
many  receptors,  somewhat  after  the  action  of  enzymes;  his  view 
is  that  the  toxin  molecule  becomes  attached  to  the  receptor,  which 
is  then  liberated  from  its  combination  with  the  cell:  on  liberation, 
the  remaining  receptors  attached  to  the  cell  manifest  greater  affinity 


SURGICAL    BACTERIA  39 

for  the  toxin  molecule  than  the  liberated  receptor  does;  so  these  two 
latter  are  separated,  the  receptor  passes  out  of  the  cell  to  serve  as 
antitoxin,  and  a  new  combination  of  the  toxin  molecule  with  an 
attached  receptor  occurs  and  is  liberated ;  then  a  new  receptor-toxin 
di--ociation  follows  as  before,  and  so  on  indefinitely,  limited  only 
by  the  capacity  and  endurance  of  the  cell.  If  the  primary  dose  of 
tin-  toxin  be  great,  there  will  be  early  exhaustion  of  the  cells,  and 
di.-rase  and  death  will  follow.  If  the  primary  dose  of  toxin  be 
slight,  there  results  insignificant  cell  destruction  and  relatively 
marked  production  of  antitoxins.  If  the  next  dose  of  toxins  be 
greater  it  will  be  tolerated,  owing  to  the  antitoxin  present,  and  a 
in  \\  stimulus  is  added  to  antitoxin  production.  This  may  be  re- 
peated until  the  animal  will  no  longer  be  disturbed  by  a  dose  which 
at  the  beginning  would  have  proved  fatal. 

It  has  been  shown  above  that  each  toxin  provokes  the  produc- 
tion of  its  own  antitoxin.  One  toxin  calls  its  antitoxin  forth  from 
one  group  of  cells  and  another  toxin  from  another  group.  There 
are,  therefore,  different  types  of  receptors  liberated  to  become  anti- 
toxins in  each  specific  infection.  This  is  true  even  when  the  differ- 
ent toxins  act  on  the  same  class  of  cells,  as  shown  by  the  inability 
of  any  antitoxin  to  neutralize  more  than  one  specific  toxin. 

Opsonins. — Among  the  chief  protective  powers  of  the  body  or 
the  tissues  are  opsonins.  They  are  the  most  important,  too,  from  a 
practical  consideration,  inasmuch  as  they  have  been  shown  capable 
of  therapeutic  application  for  a  considerable  number  of  bacterial 
species,  while  antitoxins  are  useful  in  a  very  limited  number, 
though  of  the  most  positive  value  in  these.  It  is  a  matter  of  general 
knowledge  that  there  is  such  a  thing  as  producing  changes  in  an 
individual  by  bacterial  invasion  (disease),  which  render  him  less 
su-ceptible  to  the  disease  or  wholly  insusceptible.  It  has  likewise 
long  been  known  that  by  certain  processes  (vaccination)  an  indi- 
vidual may  have  temporary  partial  immunity,  as  seen  in  the 
universal  provision  against  small-pox.  The  fact  that  a  patient  has 
had  a  disease  recently  and  recovered  from  it,  while  it  may  not  im- 
munize him  against  it,  still  may  insure  reduced  susceptibility  for  a 
time,  as  in  typhoid  fever.  Antitoxins,  agglutinins,  and  bacterioly- 
sins  are  responsible  for  a  share  in  these  results,  opsonins  for  a  much 
un-a tor  share.  To  put  the  problem  specifically,  the  fact  that  a 
patient  has  had  and  recovered  from  an  infection,  and  is  then 
more  resistant  to  it  than  before,  is  of  itself  an  assurance  that  some 
change  has  occurred  in  the  tissues,  probably  the  blood.  If  it  can 
be  determined  exactly  what  this  change  is,  how  it  affects  such  re- 
sults, and  how  its  capacity  to  produce  >uch  re>ult-  is  established, 
then  it  max  Keeome  of  use  to  the  surgeon  and  the  physician  in  com- 
batinu  and  prevent  inn  disease. 


40  PRINCIPLES   OF   SURGERY 

The  word  opsonin  means  "I  prepare  food  for."  The  signifi- 
cance of  this  name  follows. 

It  has  been  taught  for  a  long  time  that  the  leukocytes  have  the 
power  to  destroy  invading  foreign  substances,  among  them  bac- 
teria. Under  chemotaxis  above  it  was  shown  that  the  ability 
of  leukocytes  (phagocytes)  to  attack  bacteria  varied  from  a  vora- 
cious destruction  (positive  chemotaxis)  to  a  flat  refusal  to  do  phago- 
cytic  work  at  all  (negative  chemotaxis).  It  was  not  known  till 
the  epoch-making  work  of  Wright  and  Douglas  that  any  other 
agents  were  especially  concerned  in  this  phagocytic  process  than 
the  two,  leukocyte  and  bacterium.  Wright  and  Douglas  made  the 
following  experiment:  They  put  washed  living  leukocytes  into  a 
normal  salt  solution  at  blood  temperature  and  added  a  definite 
number  of  bacteria,  and  found,  after  waiting  for  a  time,  that 
phagocytosis  had  taken  place.  The  number  of  bacteria  destroyed 
per  leukocyte  was  noted.  They  then  placed  the  same  relative 
numbers  of  leukocytes  and  bacteria  in  blood-serum  from  a  healthy 
body  into  the  tube  at  blood  temperature,  and  found  that  the 
number  of  bacteria  destroyed  per  leukocyte  was  markedly  in- 
creased, demonstrating  that  the  phagocytic  action  was  enhanced 
by  the  presence  of  the  serum.  The  question  then  arose,  Does  the 
serum  increase  the  vigor  of  the  leukocytes  or  reduce  the  negative 
chemotactic  properties  of  the  bacteria,  and  render  them  more  sus- 
ceptible to  attack  and  destruction?  Bacteria  were  then  washed, 
treated  for  a  time  with  normal  blood-serum,  washed  again,  and 
placed  into  the  normal  salt  solution  with  the  leukocytes,  with  the 
same  result  that  had  occurred  when  both  were  placed  directly  into 
the  serum,  showing  the  power  serum  has  of  so  acting  on  bacteria 
as  to  enable  the  phagocytes  to  destroy  them  all  or  in  much  greater 
numbers.  Hence,  the  name  opsonins  is  given  to  the  unknown 
agents  in  the  blood  capable  of  this  action.  The  experiments  con- 
tinued— observations  were  made  of  the  blood  of  persons  who  had 
had  a  specific  infection  and  recovered.  The  opsonic  power  was 
invariably  increased  to  varying  degrees  in  different  individuals. 
Against  any  other  species  of  bacteria  it  was  not  increased.  So  op- 
sonins are  specific,  as  antitoxins  and  all  the  other  chemic  protect- 
ive agents  of  the  tissues  seem  to  be.  The  increase  of  opsonic 
power  against  staphylococcus  infection  has  no  influence  over  ty- 
phoid bacilli  or  streptococci,  but  for  staphylococci  alone.  The 
next  question  to  arise  was,  Is  this  opsonic  power  amenable  to  con- 
trol, can  it  be  raised  at  will?  The  use  of  living  bacteria,  if  they 
could  be  so  attenuated  as  to  be  harmless,  would  accomplish  it,  but 
would  be  manifestly  objectionable  and  subject  to  almost  prohibit- 
ive limitations.  By  fractional  sterilization  all  bacteria  and  spores 
of  a  culture  can  be  killed  without  affecting  the  chemic  nature  of 


SURGICAL    BACTERIA  41 

their  poisons.  Proof  of  sterility  can  be  easily  made  by  inoculation 
into  small  animals  as  a  guarantee  against  human  infection  by  hy- 
podermic administration.  This  was  done,  and  found  to  influence 
the  opsonic  power  the  same  as  when  actual  infection  had  taken 
place,  and  with  an  agent  which,  though  it  contained  a  definite 
quantity  of  bacterial  poisons,  was  yet  devoid  of  the  capacity  to 
produce  infection  at  the  site  of  injection.  The  opsonic  power  could 
now  be  controlled. 

Vaccines. — The  preparations  of  devitalized  bacteria  are  known 
as  vaccines,  whatever  the  process  of  devitalization.  They  are 
estimated  in  dosage  by  the  number  of  millions  of  dead  bacteria 
they  contain  or  represent  per  minim  or  per  cubic  centimeter. 
They  can  be  prepared  and  kept,  at  cool  temperature,  sufficiently 
long  to  be  used  satisfactorily  in  the  physician's  office.  How  long 
they  may  be  kept  is  not  known;  heat  destroys  their  value  as  soon 
as  the  temperature  reaches  80°  C.,  and  gradually  if  kept  long  above 
50°  C.  The  heat  of  a  hypodermic  syringe,  just  out  of  the  sterilizer, 
will  reduce  or  destroy  the  efficacy  of  small  doses  drawn  into  it. 

Opsonic  Index. — The  opsonic  power  of  the  individual  varies 
widely,  hence  a  standard  must  be  had  by  which  measurements 
can  be  made.  The  standard  varies  with  the  bacteria;  therefore, 
in  a  given  case  the  index  must  be  taken  for  every  species  concerned. 
The  opsonic  index  creates  a  standard  for  each  species;  it  is  the  ratio 
of  the  opsonic  power  of  the  given  case  to  that  of  normal  serum. 
To  put  it  more  tangibly,  let  the  number  of  bacteria  destroyed  by 
each  leukocyte  be  the  numerator,  and  the  number  destroyed  by 
each  leukocyte  in  normal  serum  be  the  denominator,  the  quotient 
is  the  opsonic  index  of  the  case  in  hand.  It  may  be  easily  concluded 
that  the  normal  opsonic  power  of  animals  compelled  to  combat  cer- 
tain  species  of  bacteria,  as,  for  example,  in  the  case  of  man  and  the 
staphylococci,  would  be  greater  than  that  toward  a  less  frequent 
but  equally  virulent  infection.  The  opsonic  index  cannot  be  ac- 
cepted as  the  measure  of  the  total  antibacterial  resistance,  for, 
as  has  been  shown,  there  are  other  protective  agencies  of  the  tis- 
sue-; but  it  may  be  accepted  as  a  fair  representation  of  individual 
n-Utance  in  those  cases  of  infection  against  the  bacteria  of  which 
npMinin-  may  be  developed  at  all;  there  are  certain  of  the  patho- 
genic bacteria  against  which  man  shows  no  opsonic  resistance. 
The  opsonic  index  may  be  termed  a  fair  measure  of  the  protective 
power  of  the  blood,  since  by  far  the  great  majority  of  bacterial 
species  attacking  the  living  tissues  are  overcome  by  phagocytic 
action  in  the  main,  and  since  this  action  is  efficient  for  some  types 
only  when  the  bacteria  have  been  so  acted  upon  as  to  diminish  their 
cheinotactic  re>i>tance. 

The  opsonic  index  may  be  rai-ed  as  the  result  of  an  infection 


42  PRINCIPLES   OF   SURGERY 

which  has  been  overcome;  by  the  presence  of  a  localized  infection 
which,  though  continuing  unhampered,  constantly  throws  into  the 
general  circulation  its  poisons,  hi  quantities  insufficient  to  over- 
whelm the  general  resistance;  by  the  injection  of  living  bacteria 
too  attenuated  or  in  quantities  insufficient  to  produce  disease;  by 
the  injection  of  vaccines  prepared  from  devitalized  cultures  of 
bacteria.  The  opsonic  index  may  be  lowered  by  the  same  agencies 
that  raise  it,  if  they  be  administered  in  too  great  dosage.  When 
the  opsonic  index  is  raised  or  lowered  by  infection,  the  result  is 
brought  about  by  continuous  absorption  of  infinitesimal  quantities 
of  bacterial  products,  or  by  the  gradual  destruction  of  bacteria; 
when  it  is  raised  or  lowered  artificially,  it  is  done  by  the  injection 
of  definite  doses  of  bacteria,  living  or  dead,  at  stated  intervals 
of  several  (three  to  ten)  days.  The  result  of  such  artificial  altera- 
tion is  a  reduction  of  the  index  during  the  first  few  hours,  up  to 
twenty-four,  known  as  the  negative  phase,  followed  by  a  rise  of  the 
index  to  and  above  what  it  was  at  the  beginning  of  treatment,  the 
positive  phase.  As  soon  as  the  positive  phase  has  passed  its  maxi- 
mum, but  prior  to  its  reaching  the  level  observed  at  the  beginning, 
the  second  dose  is  to  be  administered,  and  so  on. 

It  is  frequently  true  that  the  general  opsonic  index  is  high, 
while  that  of  the  fluids  in  the  infected  area  is  too  low,  by  virtue  of 
the  fact  that  the  poisons  in  the  infected  zone  are  so  much  more 
concentrated  that  they  constantly  reduce  it,  or  that  it  is  reduced 
from  the  fluids  therein  more  rapidly  than  it  can  be  replenished  from 
the  circulation,  which  is  necessarily  impaired  by  the  reparative 
processes  or  by  disturbances  associated  with  the  inflammation 
present. 

The  determination  of  adequate  dosage  of  vaccines  in  raising  the 
opsonic  index  can  be  made  absolutely  only  by  the  repeated  taking 
of  indices,  too  difficult  for  the  practitioner  and  too  costly  for  the 
patient.  By  beginning  on  doses  sufficiently  small  to  be  safe,  and 
by  gradually  increasing  the  dosage  at  each  subsequent  injection,  a 
very  satisfactory  method  is  established  for  practical  administration 
of  vaccines.  The  clinical  course  of  the  disease  is  to  be  kept  under 
surveillance,  so  that  if  any  untoward  symptoms,  as  local  increase 
of  discharge,  or  inflammatory  signs,  or  constitutional  symptoms, 
as  an  increase  of  temperature,  headache,  malaise,  muscular  or  nerve 
pains,  aching  of  the  bones  or  joints,  should  arise,  they  must  be 
taken  as  a  signal  that  the  dose  is  too  large,  too  frequent,  or  both. 
On  the  other  hand,  as  long  as  the  local  and  constitutional  symptoms 
improve,  the  increase  in  dosage  may  be  kept  up,  always  with  cau- 
tion. Vaccines  will  remain  an  efficient,  though  in  unskilled 
hands  a  dangerous,  remedy  until  some  definite  measure  of  dosage 
and  reaction  can  be  given — so  far  a  hopeless  dream. 


SURGICAL    BACTERIA  43 

There  are  certain  conditions  in  which  vaccines  are  worthless  or 
harmful.  Vaccine  therapy  cannot  be  used  in  all  cases  of  infection, 
even  of  those  infections  against  which  the  blood  can  produce  opso- 
1 1 i 1 1- .  As  a  broad  statement,  it  may  be  said  that  the  use  of  vaccines 
is  worthless  in  those  cases  where  the  amount  of  bacterial  poisons 
is  so  great  as  to  exhaust  the  natural  recuperative  power;  where 
there  is  so  great  a  toxemia  or  bacteriemia  that  the  addition  of 
more  of  the  same  poisons  could  only  result  in  the  further  reduction 
of  resistance.  Therefore,  in  septicemic  and  miliary  infections  it  is 
reasonable  to  expect  nothing  from  vaccines.  In  affections  of 
certain  structures,  for  example,  tuberculosis  of  the  adrenal  glands 
(Addison's  disease),  vaccines  are  of  harmful  influence.  In  certain 
infections,  again,  where  the  febrile  reaction  is  great,  showing  a 
marked  toxemia,  vaccines  may  be  harmful;  tuberculin  cannot  be 
ordinarily  administered  with  satisfaction  when  the  daily  tempera- 
ture reaches  100°  F.  or  more,  except  under  the  most  guarded  super- 
vi-ion.  Mixed  infections,  where  it  cannot  be  determined  which 
bacterium  is  most  detrimental,  and  where  a  mixed  vaccine  might 
be  desirable,  are  not  favorable  cases,  due  probably  to  dispropriate 
dosage  of  the  two  or  more  vaccine  elements,  so  that  one  index  may 
he  raised  while  another  is  lowered.  The  administration  of  mixed 
or  polyvalent  vaccines  may,  however,  be  attended  with  most  bril- 
liant results.  If  the  maintenance  of  a  lesion  be  reasonably  due  to 
a  single  organism,  and  if,  with  this  eliminated,  the  tissues  could 
di-pose  of  the  other,  then  the  opsonic  index  should  be  raised  against 
the  former.  One  of  the  most  notable  examples  of  successful  vac- 
cine therapy  is  the  almost  unerring  certainty  with  which  typhoid 
fever  can  be  prevented. 

Vaccines  may  be  either  autogenous  or  heterogenous;  the  former 
term  signifies  that  the  vaccine  is  made  from  a  culture  derived  from 
t  he  infection  which  is  to  be  treated  by  it,  therefore,  of  the  same  strain 
of  1  >acteria  and  the  same  virulence;  the  term  "heterogenous  vaccine" 
signifies  that  the  vaccine  is  made  from  bacteria  derived  from  some 
><>urce  outside  the  patient  to  be  treated.  Autogenous  vaccines 
wen-  thought  to  be  better  than  heterogenous,  but  the  expense  of 
preparation,  the  difficulty  of  finding  a  competent  bacteriologist 
close  at  hand,  and  the  time  requisite  for  such  manufacture,  render 
it  necessary  to  use  the  commercial  vaccines,  and  these  are  very 
satisfactory  if  manufactured  by  reliable  houses.  It  is  highly 
probable  that  autogenous  vaccines  are  not  superior  to  heterogenous 
except  where  the  part  icular  strain  of  germs  is  not  known.  Whether 
the  heterogenous  or  the  autogenous  vaccines  are  used,  the  diagno- 
>i-  must  be  made  with  unerring  accuracy.  There  can  otherwise 
come  only  harm  and  disrepute  from  their  use.  It  is  true  that  in 
>ome  instance-  a  slight  improvement  may  result  from  the  use  of  a 


44  PRINCIPLES   OF   SURGERY 

vaccine  from  a  different  family,  closely  allied,  of  bacteria,  but  it  is 
never  so  good  as  when  the  same  bacteria  are  used  and  is  often  worth- 
less. To  illustrate,  it  is  necessary  not  only  to  know  that  a  given 
infection  is  tubercular,  but  to  determine  whether  it  is  of  the  human, 
bovine,  or  avian  type;  then  the  vaccines  must  be  human,  bovine, 
or  avian  accordingly.  A  slight  good  may  result  from  the  use  of 
either  of  the  others,  but  it  is  by  no  means  certain  even  to  influence 
the  disease  beneficially. 

Immunity. — The  term  "immunity"  signifies  that  an  animal  can- 
not become  infected  by  the  bacteria  in  question.  If  such  bacteria 
be  introduced  into  the  tissues,  whether  they  are  able  to  multiply  for 
a  time  or  not,  they  cannot  produce  disease.  Immunity  is  relative 
(partial)  or  complete.  A  very  excellent  example  of  relative  im- 
munity is  seen  in  the  incomplete  protection  vaccination  gives 
against  small-pox.  The  immunized  person  may,  after  successful 
vaccination,  develop  small-pox;  it  is  of  a  mild  grade,  and  produces 
slight  symptomatic  disturbance,  no  pitting,  and  a  very  meager 
eruption. 

Further,  it  is  known  that  the  immune  animal  may  be  used  to 
confer  immunity  on  others  by  using  the  serum  or  blood  injected 
into  the  tissues  or  vessels  of  the  one  in  which  immunity  is  sought 
to  be  developed. 

To  understand  immunization,  it  is  perhaps  better  to  begin 
with  those  cases  coming  under  observation  in  which  certain 
ordinary  poisons  are  used  until  the  user  is  said  to  have  a  "drug 
habit,"  and  can  consume  harmlessly,  even  with  gratifying  physical 
and  mental  sensations,  many  times  the  average  lethal  dose  of  that 
drug.  The  more  usual  of  these  are  morphin  and  cocain.  Im- 
munity against  these  is  certainly  developed;  whether  it  is  similar 
to  the  bacterial  immunity  is  not  known;  arsenic  and  strychnin  can 
also  develop  an  immunity  in  man.  These  may  not  only  cause  no 
harm  when  the  habit  is  once  acquired,  but  a  demand,  a  hunger 
for  the  drug,  is  created.  Arsenic  may  be  injected  into  a  rabbit  in 
dosage  sufficient  to  produce  death  in  forty-eight  hours.  If  a  few 
hours  previously  one-fifth  of  the  fatal  dose  be  injected,  and  then 
the  fatal  dose,  it  is  without  effect.  Again,  the  serum  from  the 
rabbit  so  treated,  when  injected  into  a  rabbit  which  received  a 
fatal  dose,  counteracts  the  poison  so  that  it  recovers.  This  is 
perhaps  the  simplest  type  of  immunity. 

Immunization  may  similarly  be  developed  against  vegetable 
alkaloids,  robin,  ricin,  crotin,  and  others,  so  that  enormous  mul- 
tiples of  the  lethal  dose  will  be  tolerated  without  harm.  The  fer- 
ments and  enzymes,  too,  injected  in  small  doses,  cause  the  elabora- 
tion of  antienzymes  and  antiferments,  so  that  tolerance  to  these 
ordinarily  poisonous  compounds  is  produced.  Snake  venom  and 


SURGICAL    BACTERIA  45 

other  animal  poisons  act  the  same  way,  and,  by  prophylaxis,  the 
individual  may  be  immunized  against  the  stings  and  bites  of  ven- 
omous serpents  and  poisonous  insects. 

The  immunization  concerning  the  physician  in  the  most  prac- 
tical manner  is  that  against  the  toxins  of  bacteria. 

Immunity  may  be  natural  or  acquired.  Natural  immunity  is 
inherited,  that  is  racial,  accidental,  or  individual.  In  racial  im- 
munity the  species  cannot  be  affected  by  inoculations  of  the 
bacteria  in  question.  For  example,  man  is  immune  against  hog- 
cholera  and  hogs  against  human  cholera.  The  bacilli  of  bovine 
tuberculosis  do  not  attack  man  with  the  same  ease  as  human 
tubercle  bacilli  (relative  racial  immunity).  This  racial  immunity 
i>  probably  due  more  to  the  lack  of  adaptability  of  tissues  as  a  cul- 
ture-medium or  a  specially  strong  antibacterial  resistance  for  the 
specific  micro-organisms  than  to  the  presence  of  antibodies;  it  is 
km  )\vn  that  the  injection  of  serum  from  a  naturally  immune  animal 
into  one  not  immune  will  not  confer  immunity  upon  the  animal  so 
treated.  Individual,  or  accidental,  immunity — that  apparent  im- 
munity sometimes  seen  in  an  individual  belonging  to  a  species  al- 
mo-t  universally  susceptible  to  infection — is  likely  not  so  much  an 
immunity  as  a  result  of  a  chain  of  circumstances.  It  is  certainly 
not  due  to  antibodies;  besides,  it  is  difficult  to  know  the  history  of 
the  individual  so  well  as  to  be  absolutely  positive  he  has  not  had  the 
disea>e  in  question  in  a  mild  form  or  that  his  mother  did  not  suffer 
fn >n\  it  during  gestation.  It  is  likewise  not  susceptible  of  proof  by 
inoculation  except  indirectly.  There  are  now  and  then  found  indi- 
viduals who,  although  associated  intimately  with  measles,  whoop- 
in.n-cough,  small-pox,  or  other  contagious  diseases,  have  never 
developed  the  disease;  so  also,  in  spite  of  repeated  careful  vaccina- 
tion, it  is  rarely  found  impossible  to  get  a  "take."  These  facts 
do  not  so  much  establish  the  correctness  of  the  view  that  individual 
immunity  is  a  true  immunity  as  the  difficulty  of  infection,  al- 
though very  active,  taking  hold  of  tissues  under  certain  unknown 
conditions;  for  these  cases  that  have  resisted  infection  often  may 
later  develop  the  disease  under  apparently  much  less  favorable 
circumstances.  It  is  known  that  even  virulent  streptococcus  in- 
fections  would  often  refuse  to  grow  when  attempts  were  made  to 
inoculate  sarcomatous  patients  with  them. 

Acquired  Immunity. — Immunity  is  acquired  in  one  of  two 
\\ay-  fir>t.  the  individual  has  the  disease,  antibodies  are  devel- 
oped in  the  ti:-sues.  and  he  is  no  longer  susceptible  to  such  infection. 
The  contagious  diseases  of  childhood  belong  to  this  class.  This  is 
known  as  active  acquired  immunity.  The  development  of  active 
acquired  immunity  carrie-  with  it  always  the  risk  to  the  patient's 
life  and  the  chance  of  complications  and  their  subsequent  ravages. 


46  PRINCIPLES   OF   SURGERY 

It  subjects  the  patient  to  a  frightful  prognosis,  as  seen  in  the  case 
of  meningitis  (meningococcus),  diphtheria,  and  tetanus.  Second, 
immunity  may  be  produced  artificially,  without  the  risk  of  fatality 
or  serious  sequelae.  This  is  known  as  passive  acquired  immunity. 
Vaccination  against  small-pox  is  an  example  of  it,  produced  by 
inoculation  with  an  attenuated  virus  (whatever  may  be  the  nature 
of  the  cause  of  small-pox).  Antidiphtheric  serum  injected  not 
only  immunizes  against  diphtheria,  but,  if  used  during  the  presence 
of  the  disease,  is  par  excellence  curative.  Antitetanic  serum  has 
the  same  property  of  immunization  even  after  infection  has  oc- 
curred, but  has  not  the  curative  capacity  of  antidiphtheric  serum. 
Each  neutralizes  free  toxins  in  the  tissues,  and  continues  to  do  so  as 
they  are  elaborated,  until  all  its  receptors  are  used  up  or  toxins  are 
no  longer  produced.  Antitetanic  serum  does  not  seem  to  have  the 
abilty  to  neutralize  those  toxins  already  combined  with  the  recep- 
tors of  the  central  nerve-cells;  thus,  it  is  not  curative.  Diphtheria 
antitoxin,  on  the  other  hand,  in  the  presence  of  grave  constitutional 
symptoms,  may  give  relief  very  soon  after  its  use,  due  to  the  fact 
that  the  free  receptors  are  able  to  take  up  even  the  toxins  already 
combined  with  the  unseparated  receptors. 


CHAPTER   II 

ASEPSIS  AND  ANTISEPSIS 

THE  term  "septic"  is  applied  loosely  to  any  tissue  or  object 
that  has  bacteria  on  or  in  it.  The  term  "surgically  clean"  means 
the  absence  of  bacterial  contamination;  septic,  then,  means  sur- 
gically unclean  and  untrustworthy.  Owing  to  the  universal  dis- 
t  ril  nit  ion  of  bacteria,  everything,  except  living  tissues  not  exposed  to 
the  outside  world  (subcutaneous  and  submucous  tissues) ,  is  accepted 
and  acted  upon  as  being  septic  until  rendered  clean  and  sterile. 

Asepsis  means  the  attainment  and  maintenance  of  a  condition 
of  sterility;  it  means,  in  a  word,  the  absence  of  living  bacteria  or 
spores.  Asepsis  is  not  always  attainable,  so  the  term  has  come  to 
mean,  in  a  loose  way,  the  approximation  of  freedom  from  con- 
tamination. It  has  already  been  shown  that  it  is  practically 
impossible  to  be  entirely  rid  of  bacteria  in  any  class  of  operative 
work.  When  the  field  has  been  so  cleansed  that,  though  insignifi- 
cant contamination  with  bacteria  must  occur,  it  remains  insuffi- 
cient to  produce  infection,  it  is  accepted  as  aseptic  work,  but 
provided  only  that  adequate  means  have  been  exhausted  to  ac- 
complish asepsis.  The  ability  of  the  patient  to  overcome  large 
numbers  of  bacteria  introduced  at  the  time  of  operation  does  not 
prove  that  the  technic  was  aseptic.  Contrariwise,  the  occasional 
appearance  of  infection  in  long  series  of  cases  shows  conclusively 
that  the  best  efforts  are  only  proximal.  What  has,  by  a  fortunate 
accident,  turned  out  favorably  hi  one  case  or  one  tissue,  in  another 
may  end  in  death  or  in  an  embarrassing  infection. 

Antisepsis  is  the  employment  of  means  to  procure  asepsis. 
The  agents  used  are  antiseptics,  although  this  term  is  restricted  by 
usage  to  mean  usually  only  chemic  agents  which  destroy  or  devi- 
talize bacteria. 

The  agents  at  command  for  obtaining  asepsis  (antiseptic  agents) 
arc  three.  Their  relative  values  and  limits  of  application  will  ap- 
pear under  the  description  of  each. 

Antiseptic  Agents. — There  are  three  fundamental  methods  of 
producing  surgical  sterility: 

(1)  Mechanical  Method. 

(2)  Thermal  Method. 

(3)  Chemic  Method. 

Mechanical  Method  of  Producing  Asepsis. — By  the  use  of 
mechanical  agents  for  sterili/ation  i-  meant  all  those  factors  which 
may  lie  used  for  the  removal  of  Kacteria  from  the  object  to  be 

47 


48  PRINCIPLES   OF   SURGERY 

sterilized.  No  attempt  is  made  by  this  means  to  devitalize  or 
destroy  bacteria.  The  surfaces  are  to  be  cleansed  of  them  as  of  so 
much  dirt.  This  is  generally  the  most  underestimated,  and  really 
the  most  important,  part  of  sterilizing  skin  and  mucous  surfaces. 
All  foreign  material — blood,  dried  clots,  grease,  dirt,  trash,  hairs, 
rust,  and  such  like — must  be  removed  from  the  thing  to  be  steril- 
ized. This  may  be  difficult,  but  failure  to  do  so  renders  sterility 
impossible.  The  first  step  consists,  then,  hi  the  removal  of  gross 
visible  contaminating  substances.  The  razor  must  be  used  un- 
sparingly, as  nothing  is  so  sure  of  wound  contamination  as  too 
narrow  a  field  for  work,  surrounded  by  hair.  Solvents  are  used  to 
remove  all  grease  or  oil.  Nothing  conceals  bacteria  better  or  holds 
them  faster.  Sulphuric  or  acetic  ether,  alcohol,  and  benzene  are 
always  obtainable,  and  serve  as  well  as  any.  The  last  is  better 
for  cleansing  skin  grimed  and  greasy,  such  as  engineers  present; 
the  former  two,  however,  possess  the  advantage  of  having  addi- 
tional chemic  antiseptic  properties  not  now  under  consideration. 
It  may  be  accepted  that  the  chief  value  of  the  three  for  present  pur- 
poses is  their  solvent  capacity. 

The  usual  process  of  mechanical  cleansing  consists  in  the  vigor- 
ous use  of  soap  and  water,  applied  with  a  brush  or  a  piece  of  gauze. 
This  is  usually  the  first  step,  except  when  grease  is  abundant,  or 
some  other  substance,  such  as  tar,  which  does  not  yield  easily; 
here  the  solvents  are  better  applied  at  the  beginning.  The  soap, 
brush,  and  water  must  be  sterile,  and  the  washing  done  in  a  sterile 
vessel,  or  preferably  in  running  water.  Green  soap,  tincture  or 
solid,  is  the  standard  preparation.  It  should  be  kept  in  receptacles 
which  will  render  contamination  impossible.  Any  pure  toilet 
soap  answers  the  purpose  remarkably  well.  Sapolio  or  any  other 
sandy  soap  is  useful  on  vessels,  floors,  etc.  The  water  must 
be  as  warm  as  can  be  tolerated  comfortably  and  the  brush  of 
medium  stiffness;  stiff  enough  to  scrub  well,  soft  enough  not  to 
cut  the  epithelium.  The  washing  must  be  done  systematically, 
covering  the  whole  surface  several  times,  and  no  minute  spot  should 
be  allowed  to  escape.  If  a  vessel  is  used,  several  changes  of  water 
should  be  made;  if  running  water  is  used,  it  should  flow  constantly 
or  frequently  over  the  parts.  Scrubbing  should  be  done  in  at  least 
two  directions,  to  avoid  the  escape  of  any  crease  or  crevice.  All 
regions  the  brush  or  gauze  cannot  reach  must  be  cleansed  by  some 
implement  that  will  do  so  efficiently. 

After  the  scrubbing,  one  of  the  solvents  may  well  be  used  on  the 
tissues.  When  this  mechanical  method  is  well  employed,  there 
remains  little  to  be  accomplished  by  the  chemic.  It  should  be 
regarded  as  the  chief  part  of  the  process,  and  the  chemic  as  sub- 
sidiary. 


ASEPSIS    AND    ANTISEPSIS  49 

The  mechanical  method  of  cleansing  is  useful  for  the  following 
purposes:  cleansing  the  hands  for  aseptic  work;  preparing  wounds, 
.-kin.  and  mucous  surfaces  for  operative  procedures;  removal  of  the 
gross  contamination  from  untensils,  instruments,  fabrics,  furniture, 
tl( »( us,  walls,  and  such  like;  to  be  brief,  it  is  to  be  applied  whenever 
po—il>le  on  account  of  the  nature  of  the  object  to  be  sterilized.  It 
mu.-t  be  considered  as  the  most  fundamental  and  most  essential 
-tep  of  a-eptic  work;  when  it  can  possibly  be  employed,  no  other 
method  should  be  allowed  to  take  its  place.  In  other  words,  it  is 
absolutely  a  requirement  that  every  substance  intended  for  chemic 
or  thermal  sterilization  shall  first  be  clean.  An  exception  is  found 
in  those  objects  usually  sterilized  by  the  actual  flame. 

Thermal  Method. — The  most  widely  applied  and  the  most 
satisfactory,  the  ideal  means  of  accomplishing  absolute  asepsis  is  by 
the  use  of  heat.  It  may  be  applied  in  the  form  of  the  flame,  hot 
air,  hot  water,  or  steam.  The  first  two  are  known  as  dry  steriliza- 
tion. The  use  of  steam  and  boiling  water  are  known  as  moist 
-terilization.  These  various  means  of  sterilization  by  heat  are  used 
niports  best  with  the  nature  of  the  object  to  be  sterilized,  the 
time  at  our  disposal,  and  convenience  for  applying  the  various 
method-.  Few  apparatus  can  withstand  the  actual  flame;  many 
xibstances  are  destroyed  or  ruined  by  the  use  of  boiling  water  or 
-team:  others  by  air  sufficiently  heated  to  be  of  value;  yet  other 
-ill (stances  cannot  be  sterilized  by  heat  under  any  conditions.  So 
the  -election  of  the  mode  of  application  of  heat  must  be  carefully 

done. 

The  use  of  fire,  the  actual  flame,  or  of  instruments  brought  to  a 
red  or  a  white  heat  (cautery)  is  an  altogether  sure  method  in  the 
production  of  asepsis.  Platinum  loops  are  introduced  into  the 
flame  of  a  Bunsen  burner,  and,  as  soon  as  they  become  red  or  white, 
are  -terile.  Platinum  vessels  and  vessels  of  earthenware,  non-tem- 
I  M  T«  •(  1  an<  1  non-plated  metals  may  be  sterilized  the  same  way.  Metals 
which  oxidi/e  or  tarnish  easily,  and  those  whose  melting-points  are 
not  hijrh.  are  immediately  or  early  destroyed  by  such  a  process.  Ne- 
<Toticma--e-ottis-ues,  infected  ulcers,  virulent  specific  inflammatory 
areas  of  small  volume,  phagedenic  processes,  and  infected  surfaces 
of  organs  alx>ut  to  be  removed,  which,  by  accidental  contact,  may 
produce  contamination  of  a  structure  favorable  to  infection,  are 
in  a  practical  way  sterilized  l.y  red-hot  instruments  as  curative  or 
propliy lactic  treatment  in  the  hands  of  the  surgeon.  These  cau- 
terie-  may  l>e  heated  1>\  an  internal  automatic  flame,  by  being 
placed  in  embers,  a  Bunsen  flame,  or  by  electricity.  They  are 
known  a-  actual  cautery;  the  first  and  the  hist  are  the  most  u-ed 
and  the  most  convenient:  the  second  is  not  to  be  forgotten  in  ca-e 
«.I  emergency.  It  may  be  accepted  that  a.s  soon  a.-  a  ti-sue  i< 
t 


50  PRINCIPLES   OF   SURGERY 

charred  it  is  sterilized;  it  mast  never  be  forgotten  that  immedi- 
ately adjacent  to  the  eschar  abundant  bacteria  may  pass  un- 
-scttthed,  and  be  stimulated  to  higher  activity  and  meet  with  less 
resistance,  owing  to  the  damage  done  the  surrounding  living  tissue 
by  the  heat  and  the  ready  pabulum  afforded  by  that  destroyed 
but  not  removed. 

Boiling  Water. — In  efficiency,  boiling  water  stands  next  to  the 
actual  flame;  it  is  also  next  in  the  time  required  for  producing 
sterility.  Boiling  cannot  be  considered  an  instantaneous  destroyer 
o&bacteria  and  spores,  so  that  by  simply  dipping  objects  into  the 
vessel  ancl  removing  them  or  pouring  boiling  water  over  them  as 
they  lie  hi  the  tray  must  be  unsafe  practice  and  should  never  be 
trusted.  That  it  requires  time  in  each  of  the  practical  methods 
of  sterilizing  to  destroy  bacterial  life  is  a  most  essential  considera- 
tion; none  of  them  are  or  can  be  instantaneous  in  their  action. 
Boiling  water,  in  contact  with  pathogenic  bacteria,  destroys  them 
in  less  than  ten  or  fifteen  minutes  as  a  rule;  if  the  objects  to  be 
sterilized  are  not  clean,  then  the  water  may  fail  to  reach  through  the 
grease,  rust,  dirt,  or  blood-clot,  and  come  into  contact  with  the 
bacteria;  they  are  thus  subjected  to  dry  heat  of  212°  F.  for  the 
period  of  ten  or  fifteen  minutes,  which  is  inadequate.  Spores  are 
more  resistant  to  the  action  of  boiling  water  than  bacteria  are;  some 
of  them  resisting  its  action  for  longer  periods  than  fifteen  minutes. 
It  may  best  be  put  thus:  Clean  mechanically  before  boiling;  boil 
at  least  ten  minutes,  preferably  fifteen.  The  limitations  of  boiling 
water  for  sterilization  are  those  imposed  by  the  fact  that  much  of 
the  surgeon's  equipment  cannot  be  used  when  wet,  and  that  tem- 
pered instruments  may  be  damaged  by  frequent  subjection  to  the 
process.  All  that  can  be  boiled  should  be.  It  is  the  safest,  the 
easiest,  and  the  shortest  means  at  hand. 

Steam  Sterilization. — Sterilization  may  be  thoroughly  accom- 
plished by  means  of  steam  or  boiling  water.  Most  of  the  work  of 
sterilization  is  thus  accomplished,  and  the  statement  is  fairly 
accurate,  with  such  exceptions  as  are  manifest,  that  what  cannot 
conveniently  be  sterilized  with  one  may  be  sterilized  writh  the  other. 
Steam  sterilization  is  done  under  atmospheric  pressure,  or  by  higher 
pressure,  accomplished  by  allowing  its  entrance  into  an  air-tight 
chamber  containing  the  objects  to  be  sterilized.  In  the  former 
case  the  steam  is  passed  through  a  chamber  with  a  relatively  small 
outlet;  in  the  latter,  it  is  not  allowed  to  escape  until  sterilization  is 
complete.  The  time  required  should  never  be  less  than  one 
hour  for  open  steam  sterilization;  anything  short  of  forty-five 
minutes  must  be  considered  positively  unsafe;  unless  the  packages 
are  loose  enough,  and  so  prepared  as  to  allow  easy  access  of  the  live 
steam,  the  attempt  will  fail,  since  such  a  process  is  no  more  than  an 


ASEPSIS    AND    ANTISEPSIS  51 

exposure  of  the  fabrics  to  air  heated  to  a  point  short  of  212°  F. 
The  high-pressure  steam  sterilization,  by  which  is  usually  meant  a 
-ure  of  fifteen  to  thirty  pounds  to  the  square  inch  and  a  tem- 
perature of  250°  to  300°  F.,  requires  thirty  to  forty  minutes  to 
sterili/e,  but  it  is  customary  in  hospital  practice  to  expose  dress- 
ings, sheets,  etc.,  for  one  hour.  Care  must  be  taken  with  all  hiirh- 
pressure  sterilizers  to  allow  all  air  to  escape  after  filling  the  steril- 
izer, otherwise  no  sterilization.  Whether  low-pressure  or  high- 
pressure  steam  is  used,  the  sterilizer  must  not  be  packed  so  tightly 
that  easy  circulation  of  the  steam  cannot  occur.  This  mistake,  is 
sometimes  made.  The  steam  must  come  and  remain  in  contact 
with  every  part  of  the  dressings  and  vessels,  and  tight  rolling  or 
clo>e  packing  militates  against  this.  The  temperature  of  the  live- 
Meam  >terilizer  chamber  should  be  brought  up  for  a  few  minutes 
before  turning  in  the  steam,  so  as  to  prevent  condensation  .in  the 
packages.  After  sterilization,  the  steam  may  be  shut  off  and  any 
none  of  moisture  driven  off  by  hot  air. 

Hot-air  sterilization  is  of  no  practical  value  to  the  surgeon,  as  he 
has  no  need  for  it.  It  is  slow,  difficult,  and  needless. 

Fractional  Sterilization,  Pasteurization. — Many  substances  are 
so  unstable  as  to  be  unable  to  withstand  the  heat  necessary  to 
<  le-t  roy  bacteria.  The  antitoxic  sera,  bacterial  poisons,  or  bacteria 
u-ed  in  the  manufacture  of  vaccines  and  many  other  substances, 
such  as  certain  of  the  culture-media,  are  chemically  changed  by 
boiling  or  by  steam  sterilization.  Hence,  they  are  submitted  to 
temperatures  short  of  boiling,  70°  C.,  for  thirty  minutes  to  one 
hour,  on  the  next  day  the  same  process  is  repeated,  and  again  on 
the  third  or  some  subsequent  day.  Likewise  boiling,  as  was  shown 
above,  may  fail  to  kill  spores,  but  does  kill  bacteria;  after  suffi- 
cient boiling,  the  fluid  is  set  aside,  and  boiled  again  on  the  second 
ami  the  third  days.  This  allows  the  spores  present  to  develop  into 
bacteria,  if  they  will,  and  enables  us  completely  to  destroy  both. 
Subsequently  to  the  fractional,  or  intermittent,  sterilization,  cul- 
ture-; or  inoculations  are  made  from  the  fluid  sterilized.  If  a 
>eries  of  these  experiments  prove  negative,  the  sterilization  is 
accepted  as  complete;  if  one  experiment  is  positive,  the  whole 
procedure  inu-t  lie  repeated. 

Chemic  Sterilization.-  This  means  of  producing  asepsis,  like 
the  thermal  agents,  has  as  its  object  the  devitalization  or  the  de- 
struction of  bacteria  and  spores.  They  are  relied  on  only  when 
In  at  -terili/ation  is  inconvenient  or  impracticable.  In  order  to  be 
effective  ttu  chtniic  m/fN/.v,  (inti«</>ticx,  muxt  conn-  in  contact  with 
bacteria,  ami  r<  main  in  contact  long  enough  to  suspcml  thi-ir  rital  func- 
tion or  to  ulln-  tin  ir  ctninixtni  im  ]><irul>li/.  This  may  be  simply  a 
Mi>pen>ion  of  vitality.  It  has  been  shown  that  bichlorid  of 


52  PRINCIPLES   OF   SURGERY 

mercury  may  act  on  spores  (anthrax)  and  prevent  their  develop- 
ment, yet  when  it  is  precipitated  from  them  by  the  use  of  ammo- 
nium sulphid  they  are  again  capable  of  growth.  Many  chemicals 
are  almost  instantly  deadly  to  all  classes  of  bacteria,  but  they,  at 
the  same  time,  destroy  the  tissues,  the  field  of  greatest  usefulness 
for  this  class  of  antiseptics.  So  the  problem  is  to  select  a  chemic 
antiseptic  which  is  harmless  to  the  tissues  when  applied  sufficiently 
long  and  sufficiently  strong  to  produce  asepsis.  It  is  well  to  know 
that  no  chemic  antiseptic  possessed  of  such  requirements  is 
instantly  destructive  of  bacteria;  the  tune  of  exposure  cannot  be 
eliminated;  it  varies  for  different  agents  and  different  strengths  of 
solution.  The  effect  of  chemic  antisepsis  is  always  lost  on  all 
bacteria  hidden  away  hi  crevices,  crypts,  or  glands,  or  covered  by 
grease,  dirt,  or  blood;  they  do  not  reach  such  bacteria  and  cannot 
devitalize  them.  Any  beneficial  application  of  antiseptics  pre- 
supposes the  most  scrupulous  mechanical  cleansing.  The  presence 
of  tubercle  bacilli  in  undried  sputum  is  uninfluenced  by  immersing 
it  hi  a  1  :  2000  bichlorid  of  mercury  solution  for  twenty-four  hours, 
but  a  solution  of  1  : 5000  destroys  the  bacilli  in  dried  sputum  in 
the  same  tune.  This  is  due  to  the  protection  afforded  the  bacilli 
by  the  undried  sputum  from  contact  with  the  mercury.  Antiseptic 
solutions  having  oxidizing  powers,  such  as  permanganate  of  potash, 
are  exhausted  early  when  placed  in  contact  with  substances  readily 
oxidized  and  leave  the  bacteria  unhurt.  So  also  any  antiseptic 
capable  of  combination  with  other  substances  associated  with 
bacteria  must  be  continually  replenished  or  fail  of  its  purpose. 

It  is  feasible  to  take  up  only  the  more  important  antiseptics  and 
those  in  common  use  in  detail.  The  strength,  minimum  time  limit, 
and  the  micro-organisms  on  which  they  have  been  tried  out,  as  well 
as  other  important  associate  facts,  will  be  given.  This  list  may  be 
accepted  as  covering  the  more  important  antiseptics,  and  from  it 
the  reader  may  choose  what  he  finds  the  most  acceptable  for  his 
purpose.  The  antiseptic  habitually  used  by  one  surgeon  with 
impunity  may  be  so  irritating  to  another's  skin,  even  when  casually 
employed,  as  to  forbid  his  use  of  it  at  all.  Again,  the  hands  of  one 
are  ideal  for  surgical  work,  readily  cleansed  with  soap  and  water, 
and  leaving  little  to  be  done  by  antiseptics,  while  no  amount 
of  washing  or  possible  antiseptics  will  render  another  pair  of  hands 
surgically  clean. 

Bichlorid  of  mercury  is  perhaps  the  most  universally  trusted 
antiseptic.  It  is  used  in  aqueous  solutions  varying  from  1 :  2000 
to  1  :  10,000,  according  to  the  purpose.  A  solution  of  1  :  1000 
destroys  anthrax  spores  in  a  few  minutes,  and  of  1  :  10,000  in  two 
hours.  If  any  agent,  such  as  ammonium  sulphid,  be  used  to 
neutralize  the  effect  of  bichlorid  of  mercury  on  anthrax  spores, 


ASEPSIS    AND    ANTISEPSIS  53 

it  is  found  that  the  time  required  for  the  1  :  1000  solution  to  kill 
them  is  one  hour.  The  presence  of  albumin  demands  a  much 
stronger  solution  and  a  longer  time  to  destroy  bacteria.  Staphylo- 
coccus  aureus  is  not  always,  though  usually,  destroyed  by  five 
minutes'  use  of  a  1  :  1000  solution.  Since  staphylococci  are  among 
the  most  common  pyogenic  bacteria,  and  since  a  1  : 1000  solution 
fails  to  kill  them  at  times  in  five  minutes,  it  may  be  accepted  as  a 
fact  that  the  use  of  the  standard  1  : 2000  solution  cannot  be 
expected  to  render  surfaces  aseptic  by  even  a  five  minutes'  ex- 
posure; less  than  this  will  only  inhibit  them,  and  simple  immersion 
of  the  hands  and  immediate  removal  from  the  solution  is  of  little 
more  service  than  a  similar  application  of  sterile  water. 

The  efficiency  of  mercuric  chlorid  is  materially  increased,  and 
its  combination  with  albumin  is  obviated  by  the  addition  of  a 
mineral  acid,  such  as  hydrochloric,  or  of  sodium  or  ammonium 
chlorid.  Solutions  of  bichlorid  of  mercury  in  alcohol  are  more 
effective'  than  aqueous  solutions,  due  to  the  antiseptic  and  solvent 
action  of  alcohol. 

Bichlorid  of  mercury,  coming  in  contact  with  raw  surfaces  or 
granulating  wounds,  if  of  antiseptic  strength,  is  deleterious  in  its 
action  on  the  tissues,  and  leaves  the  field  with  poorer  resistance  to 
bacteria  than  if  only  sterile  water  or  salt  solution  had  been  used. 

Bichlorid  of  mercury  is  very  toxic,  and  may  be  absorbed  in  suffi- 
cient quantity  to  produce  death  when  used  on  raw  surfaces  or 
mucous  membranes.  It  is  not  to  be  injected  into  the  bowel  or 
bladder  and  allowed  to  remain;  even  if  sufficient  quantities  should 
not  be  absorbed  it  will  act  as  a  severe  irritant  to  all  mucous  sur- 
faces. It  corrodes  all  metallic  surfaces  and  dulls  cutting  instru- 
ments. Used  about  private  homes,  instructions  should  invariably 
be  given  to  dispose  of  the  solution  in  such  a  way  as  to  prevent 
poisoning  of  children  or  animals. 

Harrington's  Solution. — After  a  long  series  of  experiments  with 
antiseptio.  Harrington  found  that  all  of  the  agents  used  as  anti- 
septics must  be  used  in  greater  strength  than  the  tegumentary  sur- 
faces will  tolerate,  or  that  the  exposure  must  be  impracticably  long. 
He  then  set  about  to  increase  efficiency  and  to  reduce  the  time  of 
exposure  to  the  shortest  possible,  without,  at  the  same  time,  pro- 
ducing deleterious  effects  on  the  skin.  Doubtless  there  are  skins 
that  will  not  tolerate  Harrington's  ><>lution;  if  the  skin  will  tolerate 
it,  it  is  the  most  rapid  practical  antiseptic  known.  The  formula  is 
M  follow-: 

Hichlorid  of  mercury 0.8  gm. 

Hydrochloric  acid  60.    c.c. 

Ethyl  alcohol,  96  per  cent  <>i<>.    «•.<-. 

\\  :.I.T.  <     -  KKK).     c.c. 


54  PRINCIPLES   OF   SURGERY 

This  solution  kills  pyogenic  bacteria  on  silk  threads  suspended 
in  it  ten  seconds.  The  time  of  application  to  skin  surfaces  should 
be  from  thirty  to  sixty  seconds,  unless  one  finds  that  in  one's  own 
case  the  skin  will  tolerate  a  longer  application.  With  this,  as 
with  other  antiseptics,  the  fact  must  be  borne  in  mind  that  sterili- 
zation of  skin  surfaces  is  only  an  approach  to  asepsis.  After  use 
of  the  above  mixture  cultures  have  occasionally  shown  positive. 
Harrington's  solution,  used  on  wound  surfaces,  is  very  destructive 
to  tissue.  It  coagulates  the  blood  in  the  open  mouths  of  vessels 
and  seals  the  lymphatics,  having  the  same  effect  as  the  cautery  in 
preventing  the  dispersion  of  bacteria  through  new  atria  opened  by 
the  operation. 

Biniodid  of  Mercury. — Like  mercuric  chlorid,  this  is  a  powerful 
antiseptic,  although  it  is  used  with  less  frequency;  perhaps  this  is 
due  to  its  greater  cost.  It  is  less  irritating  and  less  likely  to  pre- 
cipitate with  albuminous  solutions,  less  toxic,  though  sufficiently 
so  to  be  guarded  against  being  used  in  such  manner  as  to  admit  of 
too  great  absorption.  It  does  not  corrode  metals  so  readily  as 
bichlorid  does,  nor  dull  cutting  instruments.  Alcoholic  solutions 
of  biniodid  of  mercury,  one  part  in  500  to  1000  parts  of  70  per  cent, 
grain  alcohol,  is  the  best  means  of  using  this  drug,  as  it  combines 
the  antiseptic  properties  of  the  two  agents.  It  may  be  used  in  aque- 
ous solution  varying  in  strength  from  1  :  500  to  1  :  2000.  Owing  to 
its  insolubility  in  water  sodium  iodid  or  potassium  iodid  must  be 
added,  in  the  ratio  of  10  parts  of  the  latter  to  1  of  the  mercuric 
iodid.  It  is  claimed  by  its  advocates  to  be  more  antiseptic  than 
bichlorid. 

Sublamin. — A  combination  of  mercuric  sulphate,  3  parts  with 
8  parts  of  ethylene-diamin,  is  used  in  1  :  500  to  1  :  1000  aqueous 
solutions  for  sterilization  of  the  skin  and  instruments;  it  does  not 
corrode  metals,  and  stands  near  bichlorid  of  mercury  in  antiseptic 
power. 

Carbolic  Acid. — This  drug  is  of  interest  from  an  historical  stand- 
point, as  it  was  used  by  Lister  as  the  antiseptic  in  the  first  at- 
tempts at  aseptic  work,  by  spraying  solutions  into  the  atmosphere 
and  over  the  wound,  the  surgeon,  and  the  assistants.  It  ranks 
among  the  very  best,  if  not  the  best,  unmixed  antiseptics  to-day. 
Only  its  toxic  and  irritative  properties  to  the  tissues  prevent  a 
wider  employment  of  it.  Carbolic  acid  leaves  the  skin  harsh  and 
dry,  and  produces  a  numbness  or  anesthetic  effect  on  the  sensory 
nerve-endings  very  objectionable  to  the  surgeon;  used  frequently, 
it  damages  the  skin  so  that  it  can  scarcely  be  sterilized.  If  solu- 
tions of  carbolic  acid  are  used  on  cutaneous  or  mucous  surfaces  they 
should  be  washed  with  alcohol  immediately  to  neutralize  its  irri- 
tant and  escharotic  action. 


ASEPSIS    ADD    ANTISEPSIS  55 

In  5  per  cent,  aqueous  solutions  carbolic  acid  kills  staphylococci 
in  from  two  to  five  minutes;  2J  per  cent,  solutions  require  from 
four  to  ten  minutes. 

A  very  valuable  field  for  the  use  of  carbolic  acid  is  found  in 
the  sterilization  of  sharp  instruments  when  it  is  not  desired  to  boil 
them.  Here  may  be  used  the  95  per  cent,  acid  in  which  the  in- 
st  ruments  are  submerged  for  a  few  minutes.  The  receptacle  should 
made  that  the  fluid  may  be  easily  poured  off;  alcohol  is  then 
poured  over  the  instruments,  and  they  are  ready  for  use.  Where 
antiseptic  and  slight  escharotic  properties  are  both  desired  carbolic 
arii I  is  the  agent  usually  employed,  such  as  swabbing  out  chronic 
infected  cavities  or  protecting  newly  wounded  surfaces  from  the 
contamination  received  at  the  time  of  injury. 

Owing  to  the  cheapness  of  crude  carbolic  acid  it  is  conveniently 
used  in  the  sterilization  of  excreta  and  clothing  or  bed  linen  con- 
taminated by  bacteria. 

The  fact  that  carbolic  acid  occasionally  causes  gangrene  by  its 
action  on  the  tissues  has  caused  many  surgeons  to  be  leery  of  its 
continued  use,  either  for  themselves  or  for  their  patients,  especially 
siicli  uses  as  the  prolonged  application,  even  in  5  per  cent,  strength. 
Not  only  so,  the  solutions  of  this  drug  are  more  likely  to  be  ab- 
>orU>d  and  produce  renal  and  constitutional  symptoms  than  the 
pure  form.  In  the  rare  cases  where  the  pure  drug  is  used  the 
dosage  must  be  guarded  to  prevent  sinister  results. 

(  resol  and  tricresol  are  derived  by  fractional  distillation  of 
crude  carbolic  acid — the  three  forms  are  orthocresol,  metacresol, 
paracresol.  Tricresol  is  a  mixture  of  the  three.  They  may  be 
used,  just  as  carbolic  acid,  in  the  same  strength  with  about  the 
same  or  a  slightly  greater  efficiency,  and  with  less  toxic  and  irri- 
tant effects.  Hammer  claims  that  1  part  of  cresol  in  200  has 
antiseptic  properties  equal  to  a  2  or  3  per  cent,  solution  of  carbolic 
acid:  other-  have  found  its  antiseptic  action  about  equal  to  that  of 
carl>olic  acid. 

Lysol  is  a  saponified  preparation,  containing,  it  is  claimed, 
:il  ><mt  50  per  cent,  cresol.  It  is  pleasant,  moderately  irritative,  and 
efficient.  Five  per  cent,  solutions  of  lysol  equal,  in  killing  power, 
that  of  the  same  strength  of  carbolic  acid.  In  weaker  solutions  it 
is  le>>  efficient  than  the  latter.  An  advantage  possessed  by  lysol 
is  that  it  combines  with  its  antiseptic  property  that  of  serving  as  a 
soap.  It  may  be  used  in  5  per  cent,  strength  for  sterilizing  the 
skin:  however,  even  1  per  cent,  solutions  may  cause  severe  burning 
of  the  mucous  membrane,  but  no  inflammatory  or  ulcerative 
action. 

<  'rtnlin  is  saponified  coal-tar  creosote,  and  is  efficient  and  safe 
in  1  to  a  per  cent.  Dilutions. 


56  PRINCIPLES   OF   SURGERY 

Potassium  permanganate,  used  in  a  saturated  solution,  produces 
death  to  staphylococci  in  fifteen  minutes.  It  is  more  antiseptic  in 
the  absence  of  organic  matter.  This  preparation  is  used  exten- 
sively for  sterilizing  the  hands;  the  stain  is  removed  by  applying 
a  solution  of  oxalic  acid,  which  has  little  antiseptic  effect.  Potas- 
sium permanganate  in  weak  solutions,  such  as  may  be  used  hi 
urethral  and  vaginal  injections,  has  an  inhibitive  action  if  long 
applied,  but  no  destructive  effect.  Hence  they  are  worth  little 
more  than  a  salt  solution,  except  for  deodorization. 

Alcohol  is  antiseptic  to  a  slight  degree — 70  per  cent,  strength 
is  more  antiseptic  than  stronger  or  weaker  preparations;  50  per 
cent,  alcohol  is  more  antiseptic  than  95  per  cent.,  and  should  be 
used  by  preference  for  the  tegumentary  surfaces.  Many  bacteria 
are  uninfluenced  by  forty-eight  hours'  application  of  alcohol,  while 
others,  among  them  tubercle  bacilli,  are  destroyed  in  five  to  ten 
minutes.  It  cannot  be  accepted  as  a  thoroughly  reliable  antiseptic. 
Its  antiseptic  value  is  much  enhanced  by  its  power  of  dissolving 
fats  and  oils;  it  is  in  this  way  that  it  liberates  bacteria  held  by  oil 
remaining  on  the  surface  after  scrubbing.  Owing  to  this  fact,  it  is 
a  better  vehicle  for  such  antiseptics  as  bichlorid  of  mercury  and 
lysol  than  water  is. 

Ether  has  little  antiseptic  power.  Anthrax  spores,  immersed  in 
ether  more  than  a  week,  develop  readily  on  their  media;  a  month's 
exposure  is  said  to  destroy  their  vitality.  The  importance  of  ether 
is  that  of  dissolving  oils  and  cleansing  in  a  mechanical  way;  it 
cannot  be  trusted  to  exert  any  valuable  antiseptic  influence  in  the 
brief  period  of  application  ordinarily  employed. 

Hydrogen  peroxid,  full  strength,  is  deadly  to  staphylococci  in 
five  minutes.  Its  expensiveness  renders  it  of  little  usefulness  for 
extensive  work,  although  it  is  employed  in  antisepticizing  wounds 
recently  made. 

lodin  has  an  antiseptic  value  of  practical  importance.  It  can 
be  used  in  weak  solutions,  but  is  of  little  service.  Its  most  im- 
portant use  is  in  the  form  of  the  tincture,  applied  directly  to  the 
skin  surface  after  mechanical  cleansing  has  been  done  and  the  skin 
thoroughly  dried.  It  is  of  special  value  in  the  sterilization  of 
emergency  cases,  such  as  penetrating  wounds  of  the  abdomen.  It  is 
applied  as  soon  as  the  mechanical  cleansing  is  finished  and  left  on  the 
surface  during  operation.  The  clinical  results  warrant  the  state- 
ment that  it  ranks  among  the  best  for  such  cases.  lodin  has  in  the 
last  few  years  been  demonstrated  to  be  one  of  the  safest  and  most  re- 
liable antiseptics,  as  was  first  demonstrated  by  Grossich.  It  is  effi- 
cacious in  both  emergency  and  routine  work.  In  emergency  cases 
the  skin  is  dry  shaved,  and,  if  scrubbing  must  be  done,  either  alcohol 
or  benzene  must  be  used.  Water  on  the  surface  immediately  prior 


ASEPSIS    AND    ANTISEPSIS  57 

to  the  application  of  iodin  is  absolutely  contraindicated.  The  anes- 
thetic is  begun,  and,  as  the  patient  approaches  surgical  anesthesia, 
the  iodin  solution  is  swabbed  over  the  entire  field  of  operation  and 
the  surface  rubbed  and  kept  moist  with  the  saturated  sponge  for 
three  or  four  minutes.  It  is  then  allowed  to  dry,  and  the  surgeon 
may  safely  proceed.  This  method  is  the  very  best  in  the  treat- 
ment of  accidental  wounds;  the  blood  and  clots  are  removed  by  dry, 
sterile  swabs,  and  the  iodin  applied  to  the  entire  raw  surface.  If 
such  treatment  is  done  in  a  reasonable  time  pus  will  rarely  be  seen. 

When  there  is  time  for  deliberate  preparation  it  is  wise  to  do  the 
dry  shaving  three  hours  before  operation,  and  paint  the  surface  with 
a  1  to  3  per  cent,  solution  of  iodin.  This  is  allowed  to  dry  and  a 
sterile  towel  is  applied.  When  anesthesia  is  complete,  or  just  be- 
fore, the  second  application  of  3  per  cent,  tincture  is  used. 

There  is  considerable  difference  in  the  practice  of  the  various 
surgeons  using  the  Grossich  method  or  modifications  of  it.  Some 
use  alcoholic  solutions,  which  I  can  vouchsafe  are  eminently  satis- 
factory; others,  including  Grossich  himself,  use  iodin  dissolved  in 
Ken/ene.  There  is  no  objection  to  employing  the  pure  tincture  of 
iodin,  except  that  it  irritates  the  skin  and  may  cause  great  distress 
unless  the  iodin  is  washed  away  with  alcohol  when  the  operation  is 
finished.  This  is  a  good  practice  even  when  the  weaker  solutions 
are  employed.  In  abdominal  work  the  skin  surface  should  ahvay> 
be  protected  with  pads  or  towels  if  the  Grossich  method  is  em- 
ployed, for  it  has  been  found  that  postoperative  adhesions  are 
much  more  frequent  if  the  peritoneum  is  allowed  to  touch  the 
iodixed  surfaces. 

Natural  Means  of  Sterilization. — Aside  from  the  internal  agen- 
eiee  combating  bacteria  present  in  the  tissues,  it  has  been  shown 
that  the  secretions  are  to  some  degree  antiseptic.  This  has  been 
i Mentioned  casually  with  reference  to  the  latter.  In  cases  of  viru- 
lent infect  K  .n  it  is  often  necessary  to  provide  adequate  escape  for  the 
bladder  contents,  and  allow  physiologic  processes  to  accomplish  a 
sterilixation  of  the  lining  and  of  the  deeper  tissues  of  the  genito- 
urinary tract,  before  undertaking  a  grave  surgical  procedure.  So 
it  is  in  cases  of  inflammation  of  the  gall-bladder,  of  the  pelvis, 
sometimes  of  the  vermiform  appendix.  When  the  work  of  sterili- 
xation  is  admittedly  incomplete,  the  infection  is  often  so  restricted 
or  M>  attenuated  as  to  render  the  field  susceptible  of  safe  work. 
So.  too,  especially  in  the  stomach,  duodenum,  and  upper  end  of  the 
jejunum.  The  sterilixat  ion  of  the  stomach  cannot  be  done  by  anti- 
septics. Deprivation  of  food  is  the  prerequisite  condition;  in 
thirty-six  hours  the  contents  of  the  stomach  will  show  few  or  no 
bacteria,  and  work  safe  from  infection  from  this  source  may  lie- 
undertaken;  a  diet  of  sterilized  food  and  drink,  frequent 


58  PRINCIPLES   OF   SURGERY 

brushing  of  the  teeth,  rinsing  the  mouth  assiduously  immediately 
after  meals,  leaves  the  stomach  with  few  bacteria  as  soon  as 
emptied,  and  shortly  (six  to  twelve  hours)  thereafter  no  bacteria  are 
to  be  found  .except  in  those  cases  where  they  were  abundant  from 
disease  or  from  inability  of  the  stomach  to  empty  its  contents 
through  a  pyloric  obstruction. 

Sterilization  of  the  Hands. — Preventive  measures  should  be 
practised  scrupulously  and  persistently  until  it  becomes  a  matter 
of  habit  to  avoid  everything  that  can  contaminate  the  hands  or 
make  them  a  favorable  harbinger  for  bacteria.  Allowing  pus  or 
other  infective  products  to  come  in  contact  with  the  hands  is  al- 
ways a  double  menace,  first  to  one's  self,  since  a  slight  abrasion  or  a 
subsequent  wound  may  admit  the  bacteria  to  the  tissues;  second, 
to  patients  on  whom  operations  are  to  be  done  subsequently,  the 
importance  of  which  can  be  seen  if  we  remember  that  it  is  admit- 
tedly impossible  in  every  instance  to  sterilize  the  skin.  So  impor- 
tant is  this  second  item  that  direct  contact  of  the  hands  with  es- 
pecially virulent  infections  should  render  the  operator  unfit  for 
service  for  at  least  twenty-four  hours,  or  until  he  has  had  opportu- 
nity to  change  all  clothing  and  bathe  again  and  again.  He  must  put 
himself  under  voluntary  quarantine  until  he  can  safely  be  trusted 
in  the  peritoneal  cavity.  The  examination  of  the  rectum  and  the 
vagina  should  be  made  with  gloved  hands,  as  any  physician  will 
gladly  admit  if  he  has  had  much  of  such  work  to  do.  Besides 
the  safety,  there  is  considerable  comfort  in  knowing  that  it  is  un- 
necessary to  contaminate  one's  self  with  what  is  universally  recog- 
nized as  filth.  All  dressings  of  septic  wounds,  should  they  be  made 
by  the  surgeon,  must  be  done  without  contamination  of  the  hands. 
The  habit  of  scratching,  expecially  the  head  or  any  part  of  one's 
body,  must  be  discarded,  for  it  necessarily  accumulates  more  or 
less  septic  material  under  the  nails,  from  whence  it  is  most  difficult 
to  remove.  Boring  and  picking  at  the  nose  serves  the  same  end 
and  in  a  more  certain  way,  and  cannot  be  tolerated. 

As  the  hands  must  not  be  polluted,  so  they  must  not  be  permitted 
to  come  to  such  a  state  that  they  will  unnaturally  or  unduly  harbor 
filth  and  bacteria.  The  skin  of  many  is  so  rough,  and  so  subject  to 
accident  or  disease,  that  this  alone  renders  such  a  one  unfit  for 
surgical  work.  If  chapping  occurs  easily  and  cannot  be  pre- 
vented, or  eczema  is  present  on  the  hands,  they  are  unfit  for  surgical 
work.  The  hands  must  not  be  allowed  to  do  rough  work  or  handle 
grease  and  dirt;  they  become  hard  and  rough,  and,  besides  being 
unclean  and  uncleanable,  they  lose  their  delicate  sense  of  touch. 
Abrasions  and  other  wounds  of  the  skin  are  ever  a  menace;  they 
may  seem  not  to  be  infected,  but  it  would  be  difficult  to  prove  that 
no  pathogenic  bacteria  may  escape  from  such  a  point  during  opera- 


ASEPSIS    AND    ANTISEPSIS  59 

t  ion.  Hence,  protection  must  be  afforded  to  the  hands  from  direct 
pollution  and  from  conditions  which  could  favor  such.  The  hands 
of  the  physician  and,  above  all,  of  the  surgeon  must  be  considered 
sacred,  for  out  of  them  are  the  issues  of  life  and  death. 

The  first  step  in  the  preparation  of  the  surgeon's  hands  for  oper- 
ation  should  be  getting  rid  of  all  clothing  that  will  possibly  touch 
the  parts  after  asepsis  is  established.  Further  instruction  will  be 
given  later  on  this  point.  Inspect  both  hands  and  forearms,  re- 
move all  hangnails,  and  put  the  free  margin  of  the  nails  and  their 
in  prime  condition.  Remove  all  rough  or  uneven  surfaces, 
but  do  nothing  capable  of  roughening  any  part  of  the  nails  or  the 
subungual  spaces.  The  second  step  is  washing  the  hands  with 
brush  or  gauze  pads,  soap  and  water.  The  brush  must  not  cut  or 
lacerate  the  flesh.  Green  soap  is  the  standard,  but  is  by  no  means 
the  only  available  one.  Any  soap  capable  of  cleansing  the  skin 
without  irritating  it  serves  the  purpose  well.  The  water  must  be 
clean  and  should  be  sterile.  If  possible,  running  water  is  to  be 
preferred:  in  default  of  running  water,  several  changes  should  be 
made  in  the  basin,  which  must  be  cleansed  at  the  beginning  and  at 
each  subsequent  change  of  water. 

The  washing  process  requires  variable  periods  of  time,  depending 
on  the  condition  of  the  hands  and  the  skill  and  understanding  of 
the  performer.  Not  less  than  ten  or  fifteen  minutes  should  be 
t  ni-ted  by  the  beginner,  or  by  any  one  knowing  of  especial  con- 
tamination of  the  hands.  It  can  be  done  satisfactorily  only  when 
« It  me  systematically.  Each  finger  is  to  be  washed  and  the  surfaces 
between  adjacent  fingers  successively.  The  sides,  the  backs,  the 
palms  of  the  hands  are  to  have  their  turn.  Simply  rubbing  back 
ami  forth  is  not  enough;  they  must  be  washed  up  and  down  and 
i TO— wi-e,  until  there  is  no  chance  of  removable  bacteria  being  left. 
The  nails  require  the  most  important  attention;  on  their  dorsal  sur- 
face the  brush  should  be  moved  vigorously  in  transverse  motion, 
then  vertically,  making  certain  that  it  reaches  the  depth  of  each 
lateral  groove;  then  transversely  in  the  subungual  space.  The 
beginner  -hould  follow  some  definite  order  of  washing  the  hands  till 

it   becomes  habitual. 

After  such  washing,  the  nails  should  be  gone  over  again  and 
reelraned  with  a  blunt  metal  or  wooden  cleaner  until  they  are 
-ati-faetory :  this  can  be  done  better  if  the  hands  are  dried.  Follow 
with  a  short  rewashing  and  rinsing  all  soap  from  the  surface  with 
-terile  water  before  using  antiseptio:  this  is  imperative  if  the 
antiseptic  contains  bichlorid  of  mercury. 

In  preparing  the  hands  for  operative  work,  it  must  be  under- 
wood that  the  term  "hands"  embraces  the  upper  extremity  from 

the  tin.uer-tips  to  the  elbows  or  above  them. 


60  PRINCIPLES   OF   SURGERY 

After  washing,  if  it  has  been  done  as  recommended  above,  there 
will  remain  little  to  be  done  by  chemicals.  It  is  necessary  to 
complete  the  work.  It  cannot  be  controverted,  however,  that  of 
the  two,  washing  is  the  more  important,  and,  if  either  were  to  be 
preferred  without  the  other,  soap  and  brush  and  water  would  be 
the  choice  of  most  surgeons. 

Whatever  antiseptic  may  be  chosen,  it  is  well  to  precede  its  use 
by  a  careful  rubbing  of  the  hands  and  forearms  with  gauze  satu- 
rated with  70  per  cent,  alcohol. 

Below  are  several  methods,  any  of  which  will  give  satisfactory 
results: 

(1)  Wash. 

(2)  Soak  in  bichlorid  of  mercury  solution  (1  :  2000)  five  to  ten 
minutes. 

(3)  Rinse  with  sterile  water. 

If  used  frequently  this  method  puts  many  hands  in  bad  condi- 
tion, as  witness  the  hands  of  interns  and  nurses.  It  is  worse,  of 
course,  if  No.  3  is  omitted. 

(1)  Wash. 

(2)  Scrub  with  alcohol  (70  per  cent.)  and  gauze. 

(3)  Soak  five  to  ten  minutes  in  bichlorid  solution  (1  :  2000). 

(4)  Rinse  with  alcohol. 

This  injures  the  skin  little  or  none,  unless  it  is  very  susceptible, 
and  is  one  of  the  most  satisfactory  methods. 

(1)  Wash. 

(2)  Soak  in  saturated  solution  of  permanganate  of  potash  until 
the  skin  is  thoroughly  brown. 

(3)  Soak  in  saturated  solution  of  oxalic  acid  till  stains  are  re- 
moved. 

(4)  Soak  in  bichlorid  of  mercury  five  minutes. 

(5)  Rinse  with  water  or  alcohol. 

This  is  objectionable  to  many  because  of  the  stinging  effect  of 
the  permanganate  and  oxalic  acid  and  the  time  required. 

(1)  Wash. 

(2)  Soak  in  Harrington's  solution  not  less  than  thirty  seconds 
nor  more  than  two  minutes,  depending  on  individual  tolerance. 

(3)  Rinse  with  water  or  alcohol. 

If  Harrington's  solution  can  be  tolerated  by  the  skin  for  one 
minute  this  is  perhaps  the  best  known  method. 

(1)  Wash. 

(2)  Scrub  with  alcohol  (70  per  cent.). 

(3)  Soak  with  carbolic  acid  solution  (aqueous),  1\  per  cent.,  for 
four  or  five  inmutes. 

(4)  Soak  in  alcohol  till  effects  of  acid  are  gone. 


ASEPSIS    AND    ANTISEPSIS  61 

The  last  is  perhaps  the  most  dangerous  method  of  the  group, 
on  account  of  the  harmful  action  of  carbolic  acid  on  the  skin  and 
its  tendency  to  produce  gangrene.  The  above  is  rendered  much 
more  pleasant  and  safer,  and  not  diminished  in  efficiency,  by  sub- 
stituting  lysol  for  carbolic  acid. 

Numerous  other  combinations  may  be  worked  out  and  are  in 
actual  service.  The  group  given  serves  to  illustrate  the  processes 
in  vogue. 

Sterilization  of  the  Operative  Field. — Because  of  the  fact  that 
the  field  of  operation  must  be  prepared  for  a  single  time,  in  a  very 
small  percentage  of  cases  oftener  than  one  time,  the  procedure  may 
l>e  carried  to  an  extent  more  extreme  than  in  sterilization  of  the 
hands  of  the  operator.  The  first  fact  to  impress  is  this — the  field 
prepared  should  be  large  enough,  so  large  an  area,  indeed,  as  will 
not  only  secure  against  infection  of  the  wound  in  case  of  an  ordinary 
incision,  but  such  that  even  the  extreme  exigencies  possible  may 
not  demand  delay  of  work  in  preparation  of  a  new  field.  Take  an 
illustration:  In  appendectomy  a  small  sterile  area  in  the  right 
iliac  region  would  give  fair  results  in  the  majority  of  cases.  There 
would  result  a  certain  percentage  of  infection  of  the  wound  from 
unavoi<  lal  >le  contact  with  the  unclean  surrounding  border  so  nearby 
from  slipping  of  the  sheets  and  towels,  and  contact  with  hands  or 
instruments.  In  a  word,  it  is  a  risky  procedure  in  the  safest  cases. 
In  many  cases  it  becomes  necessary,  from  operative  findings,  to 
enlarge  the  incision  far  beyond  the  limits  contemplated  in  the 
beginning,  or  to  make  a  second  incision  toward  the  front,  at  times 
even  in  the  loin.  Too  wide  an  area  is  rarely  prepared,  too  narrow 
often.  The  nurse  doing  preparation  must  ask  herself,  not  what  the 
average  case  requires,  but  to  what  limit  might  extreme  conditions 
require  the  surgeon  to  go,  and  act  accordingly. 

The  patient,  first,  should  have  a  general  bath  with  soap  and 
water,  except  in  minor  cases — it  is  better  in  these;  then  clean  linen 
inu-t  be  donned.  This  should  be  done  on  or  soon  after  admission. 
If  several  days  are  required  in  hospital  before  operation  the  bath 
should  be  repeated  at  least  once  daily.  Some  hours  prior  to  opera- 
tion all  hairs  should  be  shaved  from  the  operative  field  by  a  skilful 
hand  and  with  a  sharp  razor.  The  skin  must  not  be  abraded. 
The  -urface  i>  to  l»e  washed  with  soap  and  water,  using  a  brush  or 
gau/.e.  The  same  precaution  obtains  here  as  in  washing  the  hands. 
\\  hen  this  washing  is  finished  the  skin  is  to  be  washed  off  thoroughly 
with  a  fat-solvent,  alcohol,  sulphuric,  or  acetic  ether  or  benzene. 
Then  the  antiseptic  is  applied,  and  must  remain  in  contact  with  the 
skin  or  be  constantly  repeated  for  a  longer  time  than  the  maximum 
required  to  kill  pyogenic  bacteria.  Following  this  a  dry  sterile 

— ing  may  be  applied  snugly  until  the  patient  is  moved  to  the 


62  PRINCIPLES   OF   SURGERY 

operating  table,  when  the  whole  may  be  repeated,  or  the  surface 
may  simply  be  wiped  off  firmly  with  70  per  cent,  alcohol  on  gauze. 

Manifestly,  the  presence  of  an  inflammatory  or  suppurative 
process  in  the  skin  near  the  site  of  incision  jeopardizes  any  effort 
at  asepsis,  and,  unless  the  operation  is  imperative,  it  should  be 
postponed  until  such  process  subsides.  If  it  is  imperative,  then  it 
may  be  dealt  with  as  the  case  requires;  it  must  be  treated  with  the 
ordinary  antiseptic  measures.  Any  open,  discharging  spots  may 
be  cleaned  off  and  cauterized  with  carbolic  acid  or  iodin,  or  the 
actual  cautery  may  be  applied,  or  the  whole  surface  may  be  painted 
with  a  solution  of  celloidin  in  acetone,  which,  when  it  dries,  leaves 
an  impervious  membranous  covering  over  the  whole  field.  The 
incision  is  to  be  made  through  this  celloidin  coating.  One  of  the 
most  frequent  causes  of  annoyance  from  this  source,  but  a  rapidly 
disappearing  one,  is  the  use  of  blistering  applications  by  patients 
in  an  effort  to  thwart  the  need  for  surgery. 

In  emergency  work  the  above  outlined  course  cannot,  of  course, 
be  used.  The  shaving  and  washing  must  be  followed  instantly  by 
the  application  of  the  chemic  antiseptic  and  grease  solvents. 
This  may  require  to  be  begun  and  finished  in  a  very  few  minutes,  as 
in  cases  of  intra-abdominal  hemorrhage — the  field  is  splendid  for 
reception  of  bacteria,  the  vital  resistance  is  reduced  in  proportion 
to  the  hemorrhage,  the  time  allotted  for  antisepsis  is  short,  and  the 
means  applied  necessarily  meager.  Here  only  the  most  acceptable 
agents  must  be  thought  of,  and  their  success  is  a  good  index  to  their 
general  usefulness.  Aside  from  the  methods  ordinarily  in  vogue, 
there  are  two  to  be  mentioned  as  of  especial  value.  One  is  the  use 
of  Harrington's  solution  after  washing  and  shaving;  only  a  few 
minutes  are  necessary.  The  other  is  the  application  of  tincture  of 
iodin  to  the  skin  over  a  wide  enough  area.  This  must  not  be 
placed  on  after  a  motley  fashion,  but  thoroughly,  abundantly,  and 
uniformly,  so  that  it  may  find  its  way  into  all  the  open  mouths  on 
the  skin  glands.  If  any  viscus  should  protrude  through  a  wound 
it,  too,  should  be  covered  with  the  iodin. 

The  Grossich  Method. — The  tendency  in  antiseptic  work  is  to 
combine  the  simplest  with  the  most  efficient  and  quickest.  The 
Grossich  method,  or  a  modification  of  it,  is  very  excellent  and  very 
easily  done,  requiring  four  or  five  minutes  when  emergency  demands 
it.  The  skin  is  swabbed  off  with  a  1  per  cent,  solution  of  iodin  in 
benzene  after  a  dry  shave;  this  swabbing  is  repeated  three  or  four 
times,  using  fresh  swabs  each  time.  A  small  ball  of  cotton  is  held 
with  a  pair  of  forceps,  and  pressed  firmly  down  against  the  skin. 
On  to  this  cotton  tincture  of  iodin  is  poured  in  sufficient  quantity 
to  smear  over  the  region  and  wet  the  skin  with  it.  This  is  repeated 
a  time  or  two  and  the  work  may  be  begun.  If  there  is  time,  the 


ASEPSIS   AND    ANTISEPSIS  63 

same  washing  and  shaving  may  be  done  as  by  ordinary  methods, 
and  the  Grossich  method  administered  after  the  anesthetic  is  well 
under  way,  but  it  fails  to  sterilize  the  surface  if  it  is  moist.  (See 
lodin  as  an  Antiseptic.) 

Sterilization  of  Mucous  Membrane. — In  the  preparation  of 
mucous  membrane  for  surgical  work  the  mouth,  the  vagina,  and  the 
bladder  must  be  considered.  It  is  too  frequently  accepted  as  a 
truth  that  these  fields  cannot  only  not  be  sterilized,  but  cannot  be 
improved  by  antiseptic  effort,  save  in  case  of  the  vagina.  The 
mouth  should  receive,  first,  the  attention  of  a  competent  dentist, 
who  will  cleanse  the  teeth  with  as  little  laceration  of  the  gums  as 
]><>— ihle,  and  fill,  even  if  temporarily,  the  cavities  present.  The 
food  and  water  used  during  preparation  should  always  be  sterilized, 
thoroughly  wiping  the  teeth  and  the  whole  buccal  cavity  with  gauze 
and  a  mild  antiseptic  solution,  such  as  Thiersch's  solution  or  a  1 
per  cent,  carbolic  acid  solution,  or,  better  still,  50  per  cent,  alcohol, 
must  be  done  immediately  after  taking  food.  The  interdental 
spaces  are  to  be  cleansed  with  floss  silk  prior  to  the  rinsing  and 
wiping.  If  inflammatory  or  suppurative  processes  are  found  they 
must  be  cured  at  the  outset.  At  the  last  preparation  after  the 
anesthetic  is  given  the  mouth  will  be  scrubbed  with  soap  and  water 
and  then  with  70  per  cent,  alcohol.  This  method  gives  unmistak- 
ably better  results  than  the  haphazardous  trust  of  everything  to  the 
excellent  circulation  of  the  tissues  about  the  mouth. 

The  rectum  is  prepared  for  operation  by  emptying  the  bowel 
with  a  brisk  purgative,  given  thirty-six  hours  prior  to  operation,  so 
that  all  motions  may  cease  and  the  excessive  peristalsis  subside  be- 
forehand. The  food  given  during  this  thirty-six  hours  must  be 
scant  and  leave  but  little  residue  in  the  gut.  Large  enemata  (sa- 
line) should  be  given  two  or  three  times  on  the  day  before  opera- 
tion,  and  another  from  two  to  four  hours  prior  to  beginning  the 
aiiot  hit  ic.  The  region  surrounding  the  anus  is  prepared  by  one  of 
t  IK-  usual  methods  of  sterilizing  the  skin.  At  the  time  of  operation 
the  rectum  may  be  washed,  using  soap  and  water  and  swabs  on  a 
sponge-holder,  then  with  50  per  cent,  alcohol,  followed  by  saline 
BohitkxL 

The  vagina  may  be  prepared  by  practically  the  same  methods 
a-  the  >kin,  but  it  is  not  so  tolerant  of  antiseptics  as  the  former, 
alt  hough  it  tolerates  alcohol  and  1  :  2000  bichlorid  of  mercury  solu- 
tion<  without  harm.  Scrubbing  of  the  vagina  is  of  utmost  value, 
-iuce  it  i-  filled  with  folds  and  creases  which  will  never  be  reached 
by  a  careles-  nurse.  The  iodin  method  is  the  best. 

The  bladder  usually  contains  few  or  no  bacteria.  If  they  are 
|»n-fiit  in  urine,  large  quantitie>  of  water,  with  7-  to  10-grain  doses 
of  hexamethylentetramin  every  four  to  six  hours  for  a  few  days,  will 


64  PRINCIPLES   OF   SURGERY 

reduce  the  number  or  eliminate  them.  If  residual  urine  or  inflam- 
mation of  the  bladder  is  present,  systematic  catheterization  three 
or  four  times  a  day,  and  irrigation  with  a  weak  solution  of  potas- 
sium permanganate  or  bichlorid  of  mercury  or  a  standard  boric 
acid  solution  or  even  normal  salt  solution,  tend  to  eliminate  the 
infection.  If  the  source  of  infection  is  the  kidney  substance  or  its 
pelvis,  it  will  continue  to  pollute  the  bladder  unless  it  can  be  dealt 
with  by  flushing  and  the  administration  of  hexamethylentetramin 
or  by  direct  irrigation.  At  the  time  of  operation  the  bladder  should 
be  washed  several  times  with  salt  or  boric  acid  solution. 

Sterilization  of  Accidental  Wounds. — The  same  mechanical 
methods  of  sterilization  that  are  used  in  uninjured  surfaces  are 
applicable  to  wounds.  If  it  is  a  penetrating  wound,  care  must  be 
had  not  to  allow  entrance  of  solutions  or  debris  into  the  serous 
cavity.  All  hair,  blood-clots,  grease,  dirt,  and  devitalized  tissues 
must  be  removed  from  the  wound;  the  region  must  be  shaved  and 
the  whole  surface,  wound  and  all,  must  be  thoroughly  washed,  using 
green  soap,  or  its  tincture,  and  water.  Benzene  or  iodized  benzene, 
1  per  cent.,  may  be  used  to  the  greatest  advantage,  especially  hi 
wounds  of  the  hands  of  mechanics  and  trainmen.  This  antiseptic 
is  used  after  the  mechanical  cleansing  with  non-aqueous  solutions. 
If  a  bichlorid  solution  is  employed,  the  mercury  is  precipitated  by 
blood  and  serum,  and  so  must  be  applied  in  a  constant  stream,  or 
the  part  must  be  immersed  in  several  succeeding  solutions.  It  has 
a  deleterious  effect  on  the  tissues  of  the  wound  surface;  for  these 
two  reasons  it  is  far  from  satisfactory  in  this  class  of  work,  and  is 
less  valuable  probably  than  normal  salt  solution.  Lysol  or  car- 
bolic acid  may  be  used  pure,  or  in  adequate  solutions,  and  followed 
by  alcohol.  These  may  be  used  even  on  so  delicate  structures  as 
the  brain  substance,  when  lacerated  and  infected;  they  must  be 
so  applied  hi  such  cavities  that  they  cannot  escape  into  surrounding 
spaces  to  cause  mischief  later.  Tincture  of  iodin  may  be  used  the 
same  way  with  the  same  good  results.  It  may  be  followed  with  al- 
cohol to  remove  the  excess,  and  should  not  be  used  on  large  wounds, 
to  be  closed  subsequently  without  drainage,  lest  iodism  result.  Har- 
rington's solution  is  effective  in  this  class  of  work,  but  is  more 
destructive  to  tissue  than  either  lysol,  carbolic  acid,  or  iodin. 
In  lieu  of  these  more  efficient  agents  alcohol  may  be  poured  into  the 
wound  or  applied  on  sponges  for  a  few  minutes.  All  these  drugs 
are  painful,  and,  if  the  wound  is  large,  it  is  better  to  anesthetize  the 
patient  before  applying  them. 

Sterilization  of  Instruments. — Every  instrument  in  the  surgical 
armamentarium  should  be  made  of  material  that  will  tolerate  boil- 
ing; unfortunately,  frequent  boiling  untempers  cutting  instru- 
ments somewhat,  and,  for  this  reason,  many  surgeons  object  to 


ASEPSIS    AND    ANTISEPSIS  65 

having  knives  and  scissors  so  sterilized;  others  boil  them  and  take 
the  consequences.  Temper  is  lost  much  more  readily  if  the  in- 
struments lie  in  contact  with  the  vessel  next  to  the  flame.  Every 
instrument  is  to  be  thoroughly  cleansed  as  soon  as  used;  this  pre- 
vents rusting  and  drying  of  body  fluids  on  their  surface.  Besides, 
they  are  ready  for  sterilization  when  needed  again.  The  water 
must  be  foiling  when  the  instruments  are  submerged  in  it;  this 
drives  off  the  excess  of  oxygen  and  prevents  rusting;  the  addition  of 
soda,  1  per  cent,  of  the  carbonate,  is  further  corrective  against 
ruMing;  besides,  it  raises  the  boiling-point  to  219°  F.,  an  advantage, 
<  -|>< -dally  in  high  altitudes.  The  instruments  should  never  be 
i  •( >iled  less  than  ten  minutes.  Pouring  boiling  water  over  them  is  a 
-nan-  and  a  delusion.  If  the  instruments  are  to  be  carried  some 
Distance  before  using  they  must  be  separated,  dried  with  sterile 
towels,  and  reunited,  or  rusting  will  occur.  Knives  should  be 
protected  by  wrapping  with  cotton  to  avoid  dulling  and  gapping 
their  edges.  It  is  better  to  boil  them  separately,  if  at  all. 

Those  instruments  which  are  not  boiled  may  be  immersed  in 
pure  carbolic  acid  or  lysol  in  a  vessel  with  a  spout  at  one  corner, 
so  that  the  fluid  may  be  poured  off;  alcohol  is  then  poured  over 
them.  In  case  water  is  used  for  this  purpose  instead  of  alcohol, 
they  should  be  thoroughly  rinsed  before  using,  since  carbolic  acid 
lie-  undissolved  on  the  under  surface  or  at  the  bottom  of  the  vessel 
and  burns  the  tissues  it  touches. 

Tans,  receptacles,  and  apparatus  are  to  be  sterilized  by  the 
same  method  as-  that  given  for  instruments.  In  emergency,  pans 
may  lie  sterilized  fairly  well  by  pouring  a  little  alcohol  into  them, 
bringing  it  into  contact  with  the  whole  surface,  and  setting  fire  to 
it;  continue,  while  the  flame  lasts,  to  shift  the  position  of  the  vessel 
-o  that  the  blaze  comes  often  hi  contact  with  the  surface.  It  is 
to  he  thought  of  only  when  boiling  cannot  be  done,  a  rare  occasion, 
and  should  not  be  ranked  among  acceptable  methods. 

Sterilization  of  Dressings  and  Fabrics. — These  are  to  be 
\\rappcd  loosely  in  cloth  fastened  with  pins  and  sterilized  with 
-team,  preferably  under  pressure.  Boiling  them  in  water  sterilizes 
just  as  satisfactorily,  but  it  leaves  them  wet,  an  insurmountable 
objection  for  many  uses. 

Rubber  goods  are  sterilized  by  boiling;  they  must  be  wrapped 
and  kept  away  from  the  sides  and  bottom  of  the  boiler. 


CHAPTER  III 

THE  PROCESS  OF  HEALING 

WHEN  an  injury  is  done  to  tissue  an  effort  is  put  forth  to  bring 
it  back  as  nearly  to  normal  as  possible  to  repair  the  derangement 
produced.  It  may  be  understood  in  the  beginning  that  the  repair 
is  most  often  only  a  repair  and  not  a  restoration  of  the  injured 
or  removed  tissue  in  kind.  There  are  three  fundamental  histologic 
elements  concerned  chiefly  in  the  repair  of  tissue.  One,  two,  or  all 
of  them  may  be  produced  in  the  healing  of  the  same  wound.  These 
elemental  tissues  are  tegumentary  cells,  white  fibrous  tissue,  and 
bone,  all  physiologically  passive  tissues.  If  any  further  restora- 
tion of  actively  functionating  tissues  occurs,  it  is  well;  examples  of 
this  will  be  given  in  detail  later.  The  rule  remains,  however,  that 
bone  is  repaired  by  bone,  epithelial  coverings  by  multiplication  of 
epithelial  cells,  and  the  remaining  tissues  by  white  fibrous  tissue,  or 
scar  tissue. 

The  process  of  healing  is  also  known  as  the  healing  of  wounds, 
the  repair  of  tissues,  the  process  of  repair,  and  the  healing  process. 

Broadly  speaking,  it  may  be  stated  that  the  more  highly 
organized  a  tissue  is,  or  the  more  specialized  an  organ,  the  less  it  is 
capable  of  reproducing  its  functionating  cells.  It  is  shown  by 
embryologists  how  tractable  the  tissues  of  lowly  organized  animals 
and  of  early  fetal  developments  are,  so  that,  by  dealing  with  these, 
they  may  very  materially  alter  the  course  of  development  in  the 
adult  forms.  After  specialization  is  finished  and  the  perfect  struc- 
ture of  the  higher  types  of  animals  is  reached  this  adaptability  is 
lost  irreparably.  The  blood  may  be  spilled  and  replenished  by 
blood,  bone  by  bone,  fibrous  tissue  by  fibrous  tissue,  epithelium  by 
epithelium,  but  a  portion  of  the  muscle  removed  is  lost,  and  glandu- 
lar tissue,  nerve-centers,  and  such  like,  when  damaged,  can  only  be 
patched  by  the  almost  universal  new-formed  tissue. 

The  same  process  as  that  manifested  in  the  repair  of  wounds  is 
shown  in  the  presence  of  irritation,  especially  if  it  is  prolonged. 
This  will  be  discussed  under  Inflammation. 

Healing  of  Soft  Structures. — For  the  sake  of  simplicity  this 
may  be  stated,  therefore,  to  be  one  process;  subdivisions  of  the  proc- 
ess depends  on  circumstances  under  which  the  healing  must  occur, 
without  alteration  of  a  single  essential  factor  contributing  to  the 
ultimate  result  and  with  no  variation  of  the  product  when  com- 
pleted. These  subdivisions  are,  therefore,  concerned  not  with  the 

66 


THE  PROCESS  OF  HEALING  67 

mode  of  healing,  but  with  the  conditions  found  while  healing  goes 
on.     There  are  three  types  of  the  healing  process: 

(1)  Healing  by  first  intention,  healing  per  primam,  primary 
union,  direct  union. 

(2)  Healing  by  second  intention,  healing  of  an  open  wound,  or 
healing  by  granulation. 

(3)  Healing  by  third  intention,  or  the  union  of  granulating  sur- 
faces directly  one  to  another. 

Healing  by  First  Intention. — The  conditions  under  which  pri- 
mary union  takes  place  are  definite,  and  must  be  present,  or  a 
failure  of  direct  union  occurs.  The  surface  of  the  wound  must  be 
clean  and  the  mouths  of  the  blood-vessels  closed,  so  that  the  wound 
is  dry.  The  wound  surfaces  must  be  approximated  throughout 
their  entire  depth,  and  the  structures  holding  them  together  must 
not  be  so  tightly  drawn  as  to  shut  off  the  circulation  within  their 
grasp.  The  preceding  conditions  are  of  relative  importance, 
since  primary  union  occurs  in  spite  of  failure  to  comply  with  one  or 
more  of  them  absolutely.  The  next  condition  is  most  important. 
There  must  be  no  infection;  the  wound  must  be  aseptic;  if  there  is 
eont animation  by  bacteria,  they  must  be  in  such  numbers  or  so 
attenuated  that  the  tissues  can  dispose  of  them  without  extensive 
cell  destruction.  Suppose,  then,  that  the  wound  is  clean,  dry,  and 
closed,  there  will  remain  a  certain  dead  space,  however  narrow,  into 
which  blood  and  serum  escapes  until  it  overflows  at  the  surface. 
Some  of  this  fluid  escapes  on  to  the  surface  or  the  dressings,  where  it 
dries;  in  the  former  instance  this  constitutes  a  scab,  narrow  and 
long,  which  serves  the  single  purpose  of  an  impervious  dressing. 
The  fluid  accumulated  in  the  wound  coagulates  within  the  first 
twenty-four  hours,  sealing  the  surfaces  and  lips  of  the  wound  to- 
gether as  so  much  mucilage  holds  two  sheets  of  paper  together; 
it  is  a  mechanical  bond  of  union,  and  from  the  histologic  standpoint 
is  a  foreign  body,  serving  a  temporary  purpose,  ultimately  to  be 
removed  as  healing  advances.  This  mechanical  bond  of  union  fills 
every  nook  and  cranny  that  may  be  present  on  the  wound  surface. 
The  cells  damaged  by  the  agent  producing  the  wound  may  practi- 
cally be  considered  as  a  part  of  the  mechanical  bond  of  union,  for 
they  undergo  degeneration  and  are  disposed  of  by  the  same  process 
as  the  clotted  blood  and  serum. 

Acted  upon  by  the  irritation  of  the  trauma,  the  capillaries 
adjacent  are  somewhat  dilated  and  a  deposit  of  leukocytes  is  made 
about  the  wound  surfaces  ami  back  into  the  tissues,  a  little  beyond 
the  limits  of  the  injury.  They  completely  surround  the  clot  which 
seals  the  surfaces  together.  The  vascular  changes  do  not  go  be- 
yond the  >ta^e  of  a  slight  hvperemia.  In  those  wounds  where  no 
infection  i.-  pn-mt  the  hyperemic  condition  i-  not  -ufficient  usually 


68  PRINCIPLES   OF   SURGERY 

to  produce  any  visible  change  more  than  a  faint  blush  near  the 
edges  of  the  wound.  The  leukocytes  begin  their  phagocytic  action 
at  once  in  clearing  up  the  injured  cells  and  attack  the  walls  of  the 
clot.  The  leukocytes  are  ultimately  removed  from  the  tissues; 
they,  too,  perform  a  service  and  are  disposed  of. 

Soon  after  the  above  occurrence  takes  place  there  appear  in  the 
rear  of  the  leukocytes  large,  irregular-shaped  cells  with  large  nuclei 
and  abundant  protoplasm;  they  resemble  epithelial  cells  suffi- 
ciently to  be  spoken  of  as  epithelioid  cells;  they  are  called  fibroblasts, 
for  from  them  the  ultimate  product  of  fibrous  (cicatricial)  tissue  is 
developed. 

The  source  of  fibroblasts  is  a  mooted  question.  It  is  generally 
accepted  that  they  are  descended  from  the  neighboring  fixed  con- 
nective-tissue cells,  and  from  the  endothelial  cells  of  capillaries, 
lymphatics,  and  lymph-spaces  in  the  field  of  injury.  There  is  also 
unequivocal  evidence  that  at  least  some  of  the  fibroblasts  are  brought 
to  the  field  by  the  blood-current;  the  origin  of  them  is  not  known. 
Fibroblasts  are  of  various  shapes,  some  round,  others  oval,  some 
elongated  and  bipolar;  others  are  multipolar.  The  mass  of  tissue 
made  up  of  fibroblasts  is  known  as  embryonic  tissue;  there  are  no 
blood-vessels  as  yet  developed  in  this  mass. 

The  fibroblasts  are  the  precursors  of  scar  tissue.  After  fibro- 
blastic  tissue  is  well  on  its  way  there  appear  little  processes,  spring- 
ing from  the  capillaries  up  into  the  embryonic  mass.  They  are 
solid  at  first,  very  thin,  and  made  up  of  granular  protoplasm.  They 
are  outgrowths  from  the  endothelial  cells  of  the  capillaries.  The 
free  end  appears  solid;  as  elongation  continues  the  process  begins 
to  hollow  out  at  the  attached  extremity  and  blood  enters  its 
base.  These  processes  are  called  capillary  buds.  They  grow  into 
the  embryonic  tissue  in  great  numbers;  the  free  end  of  one  unites 
with  the  free  end  of  another,  or,  if  it  fails  to  find  such  in  due  time, 
it  loops  back  and  unites  either  with  another  original  capillary  or 
the  one  from  which  it  sprang.  At  times  they  are  seen  unattached, 
appearing  as  blind  tubes.  These  new-formed  blood-vessels  are 
named  capillary  loops.  After  the  capillary  bud  begins  to  show  a 
lumen  the  endothelial  cells  spread  from  the  old  capillaries  and  line 
it.  When  the  free  ends  become  attached  the  lumen  is  soon  com- 
pleted and  the  endothelial  lining  finished,  so  that  a  new  capillary 
results,  and  the  blood  circulating  through  it  is  carried  into  the  em- 
bryonic tissue. 

After  capillaries  grow  into  embryonic  tissue  it  is  called  granula- 
tion tissue. 

While  capillary  loops  are  forming  the  embryonic  tissue  advances, 
and  secondary  loops  spring  from  the  first  in  the  same  manner  until 
the  capillary  buds  are  able  to  meet  from  one  side  of  the  wound  to 


THE    PROCESS    OF    HEALING  O9 

the  other,  thus  bridging  the  chasm  occupied  a  few  days  ago  by  a 
lifeless  clot,  and  thus  establishing  a  vital  bond  of  union. 

The  time  required  for  the  healing  process  to  advance  to  this 
point  is  three  or  four  days  from  the  date  of  closure,  if  approxima- 
tion has  been  perfect.  It  is  longer  if  the  approximation  has  not 
been  perfect,  inasmuch  as  there  is  a  thicker  clot  to  be  removed. 
A-  the  granulation  tissue  grows  a  few  hours  older  the  epithelioid 


l-iu.   1.  Cicatrization  following  a  severe  traumatism  to  lower  back.     Note 
displacement  of  the  anal  outlet . 

eell>  become  more  and  more  elongated  and  thinner,  while  at  their 
surface  can  he  seen  the  fibrils  of  beginning  connective  tissue.  It 
i-  not  x -tiled  whether  these  connective-tissue  fibers  are  derived 
from  spotting  up  of  the  fibroblMttocelk  or  ue  produced  ilcngBtde  in 

the  intercellular  -uUtaiice.  Thi-  much  is  certain,  that,  as  the 
connective  ti— tie  l.eeonie<  more  al'iin<lant,  the  fihrol»la>tic  cells 
jirmv  smaller,  leaving  only  the  nudeu-  ;iiul  a  -mall  amount  of  cell 

-lll»tatiee    <.  coniieetn -e-tis-ue   cell-    . 


70  PRINCIPLES   OF   SURGERY 

Cicatrization. — On  formation  of  the  fibrils  from  the  epithelioid 
cells  these  fibrils  begin  to  contract,  the  last  step  in  the  production 
of  scar-tissue.  This  contraction  is  due  to  the  diappearance  of 
moisture  from  the  succulent  new-formed  tissues,  and  the  whole 
granulation  mass  shrinks  into  a  smaller  volume.  It  is  essentially 
a  very  slow  process,  and  requires  some  weeks  or  even  months  for 
its  completion.  As  contraction  or  cicatrization  of  the  new-formed 
fibrous  tissue  takes  place  numerous  small  vessels  coursing  through 
it  are  collapsed,  and  ultimately  obliterated.  Hence,  while  in  a 
newly  formed  scar  the  number  of  capillaries  is  greater  than  normal 
and  the  scar  is  red,  in  the  cicatrix  the  number  of  vessels  is  much  less 
than  in  normal  tissue  and  the  scar  is  pale.  New  scars  can  thus  be 
readily  distinguished  from  old  ones.  On  account  of  the  poor  blood- 
supply  of  cicatrices  they  are  incapable  of  resisting  destructive 
agents  as  well  as  normal  tissue  and  often  ulcerate;  for  the  same 
reason  operation  must  not  be  made  by  incising  large  scars 
and  trusting  them  to  reunite  on  closure.  They  are  either  to  be 
avoided  or,  if  possible,  excised  at  the  time  of  operation;  the 
circulation  of  cicatricial  tissue  is  too  poor  to  trust  in  an  important 
place.  The  denser  the  scar  is  and  the  larger,  the  more  likely  it  is 
to  succumb  to  gangrenous,  ulcerative,  and  inflammatory  changes 
when  damaged  by  incision  or  when  called  upon  to  do  more  than 
maintain  its  own  existence. 

Epidermization. — As  soon  as  the  mechanical  bond  of  union  is 
established  the  tegumentary  cells  limiting  the  periphery  of  the 
wound  begin  to  spread  inward  by  multiplication,  to  cover  the  rent 
in  the  skin  or  mucous  membrane;  they  advance,  as  the  granulation 
tissue  does,  until  the  gap  is  covered.  The  whole  thickness  of  the 
skin  is  not  regenerated;  only  those  cells  whose  function  is  the  pas- 
sive one  of  covering  in  the  underlying  structure  are  developed;  no 
hair-follicles,  therefore,  no  sebaceous  or  sweat-glands,  no  papillae, 
are  found  over  the  cicatrix.  It  is  simply  covered  with  tegumentary 
epithelium. 

From  the  time  of  closure  of  a  clean  wound  to  the  formation  of 
the  mechanical  bond  of  union  is  twelve  to  twenty-four  hours;  from 
the  time  of  appearance  of  the  mechanical  bond  of  union  to  its 
destruction  by  the  leukocytes  is  two  or  three  days;  from  the  time 
of  removal  of  the  mechanical  bond  of  union  to  complete  estab- 
lishment of  granulation  tissue  is  two  to  three  days.  So  the  period 
of  time  from  the  production  of  the  wound  to  constructive  comple- 
tion of  healing  is  about  six  days.  Short  of  this  time  stitches  are 
rarely  removed,  except  for  special  reasons  and  in  small  wounds. 
Those  wounds  made  in  very  vascular  regions,  such  as  the  face, 
complete  the  process  a  day  or  two  sooner;  while  those  made  in 
tissues  which  have  a  poor  blood-supply  require  a  little  longer  time. 


THE    PROCESS    OF   HEALING  71 

At  this  stage  of  the  healing  process  the  work  must  not  be  con- 
sidered finished.  It  is  easy  to  enter  a  blunt  instrument  through  the 
granulation  tissue  of  a  healed  wound  at  the  sixth  day  or  even  later. 
This  is  productive  of  little  or  no  pain,  since  there  has  been  no 
regeneration  of  nerves  this  early  in  the  new-formed  tissue.  The 
fragility  of  the  new-formed  tissue  has  a  very  practical  bearing,  in 
>o  tar  :t>  there  is  great  tendency  on  the  part  of  some  operators  to 
rush  thrir  patients  out  of  bed  and  away  from  the  hospital  at  the 
earliest  possible  date.  If  no  tension  is  to  be  brought  upon  the  scar 
no  harm  results;  if  tension  is  to  be  brought  by  such  action,  more 
or  less  stretching  of  the  scar  ensues;  this  may  be  carried  to  such 
an  extent  as  to  render  the  necessary  support  void,  or  it  may  pro- 
duce severance  of  the  new  wound  edges  subcutaneously,  and 
1  tro«  luce  a  postoperative  hernia.  No  wound  should  be  trusted  to 
resist  tension  or  pressure  short  of  two  or  three  weeks  after  opera- 
tion, particularly  in  that  class  of  cases  so  well  illustrated  by  herniae. 
There  are  other  conditions,  outweighing  this  one,  that  at  times 
compel  the  surgeon  to  take  chances  with  the  wound;  they  are  not 
routine. 

In  the  older  subdivisions  of  the  process  of  repair  healing  by 
blood-clot  was  mentioned  as  one  of  the  five.  It  is  the  same  as  the 
process  described  above,  except  that  in  healing  by  blood-clot  the 
separation  of  the  wound  surfaces  is  greater,  the  mechanical  bond 
of  union  wider,  and  the  time  requisite  to  finish  the  building  of 
granulation  tissue  across  it  proportionately  extended.  In  truth, 
primary  healing  is  nothing  less  than  healing  by  blood-clot,  with  the 
clot  reduced  to  a  minimum  thickness. 

Healing  by  Second  Intention. — When  circumstances  are  such 
as  to  preclude  healing  by  primary  union,  wounds  are  left  the  al- 
ternative  of  healing  by  second  intention  or  as  open  wounds.  The 
conditions  favorable  to  primary  union  may  be  present  at  the  out- 
set, but  later,  owing  to  accident  or  infection,  especially  such 
virulent  infections  as  streptococci,  they  may  be  so  altered  as  to 
compel  a  change  from  first  to  second  intention.  Healing  by 
second  intention  may  occur  in  wounds  that  have  been  closed,  from 
inability  of  the  tissue  to  establish  under  the  circumstances  some  of 
the  nei •« — ;:i -y  steps  of  primary  or  direct  union;  infection  is  the  chief 
cau-e  of  failure  of  primary  union  in  closed  wounds,  which,  if  it  be 
intense  enough  to  cause  inflammatory  reaction  or  suppuration, 
invariably  results  in  a  more  or  less  exclusive  failure  of  primary 
union;  sutures  tied  too  tightly  and  dressings  producing  marked 
pres.Mire  may  so  interfere  with  the  local  circulation  as  to  cause 
non-union.  Certain  constitutional  conditions,  of  which  the  most 
notable  perhaps  is  diabetr-  mellitus.  may  render  the  tissues  unable 
to  respond  to  the  demands  of  the  healing  process,  and  so  produce 


72  PRINCIPLES   OF   SURGERY 

failure.  Under  all  such  circumstances  healing,  if  occurring  at  all, 
must  be  by  second  intention.  In  all  cases,  when  the  nature  of 
the  wound  or  the  circumstances  present  render  it  impossible  or 
inadvisable  to  make  closure,  healing  by  second  intention  occurs, 
so  it  is  called  healing  of  an  open  wound.  It  occurs  in  these  cases 
in  the  presence  or  in  the  absence  of  infection.  In  many  conditions 
where  surgical  procedures  are  resorted  to  for  the  relief  of  patho- 
logic lesions  due  to  infection,  such  as  abscess  or  fistula  in  ano,  it  is 
necessary  to  deal  with  the  lesion  in  such  a  manner  as  to  warrant 
healing  from  the  bottom,  or  by  second  intention.  Hence,  healing 
by  second  intention  is  not  to  be  looked  upon  as  an  unfortunate 
variation  from  the  ideal  type  of  healing,  but  as  a  very  useful  means 
of  accomplishing  drainage,  on  the  one  hand,  while,  on  the  other, 
closure  of  the  cavity  drained  is  being  accomplished  by  the  forma- 
tion of  granulation  tissue. 

Healing  by  second  intention  utilizes  the  same  elements  in  its 
accomplishment,  and  these  elements  are  derived  from  the  same 
sources  as  in  primary  union.  Let  us  take  an  ideal  wound  for  this 
type  of  healing — it  is  open,  a  part  of  the  skin  has  been  removed 
or  destroyed,  and  closure  is  thereby  rendered  impossible.  No 
mechanical  bond  of  union  forms  or  can  form;  there  is  no  union. 
The  hemorrhage  controlled,  the  wound  is  cleansed,  the  dressings  are 
applied.  There  will  be  considerable  oozing  of  serum  and  lymph  and 
blood  into  the  dressing  in  the  first  twenty-four  to  thirty-six  hours. 
This  is  afterward  reduced,  as  a  rule,  to  a  serous  exudate.  The 
same  vascular  changes  occur  around  the  base  of  the  wound  as  in 
primary  union.  There  are  a  number  of  leukocytes  deposited  in 
the  upper  layers  of  the  wound  surface  among  the  crippled  cells  and 
on  the  surface.  Numbers  of  them  escape  with  the  discharging 
serum  and  are  wasted.  Fixed  connective-tissue  cells,  lymphatic 
and  capillary  endothelial  cells,  and  perhaps  cells  brought  from 
remote  points  in  the  circulating  blood  contribute  to  originate 
fibroblasts,  the  accumulation  of  which  constitutes  a  covering  of 
embryonic  tissue  for  the  healthy  underlying  region.  These  be- 
come granulation  tissue  by  receiving  capillary  loops,  and  are  soon 
converted  into  rudimentary  fibrous  tissue  which  cicatrizes  after  a 
few  days.  Cicatrization  has  additional  importance  in  this  class  of 
wounds,  for,  being  attached  to  the  whole  of  the  raw  surface,  when 
contraction  takes  place  the  edges  of  the  wound  are  gradually 
drawn  in  toward  the  center,  making  the  surface  area  continually 
smaller  as  long  as  the  healing  process  continues.  The  epidermis 
begins  to  cover  the  granulation  tissue  at  the  periphery,  and 
gradually  spreads  inward  as  the  wound  cavity  fills  up  until  the 
scar  is  covered  by  epithelium.  The  new-formed  epithelium  appears 
as  a  narrow  ring,  -^  to  TTF  inch  wide,  surrounding  the  raw  surface. 


THE  PROCESS  OF  HEALING  73 

Epidermization  is  very  materially  helped  by  the  process  of  cica- 
trization, for,  as  the  epidermis  is  building  new  integument,  the 
contraction  of  the  scar-tissue  is  continuously  narrowing  the  area 
to  be  covered,  so  that  the  actual  area  covered  by  new  epithelium 
is  often  no  more  than  one-fourth  or  one-half  the  size  of  the  original 
wound.  The  laxity  of  the  tissue  in  which  the  healing  occurs  exerts 
great  influence  on  the  result  accomplished  by  cicatrization.  The 
looser  the  tissue,  the  greater  the  contraction  and  the  smaller  the 
size  of  the  scar;  the  contrary  proposition  is  also  true;  the  denser 
and  more  inelastic  the  tissue,  the  larger  the  scar. 

The  presence  of  infection  and  pus  in  such  a  wound  does  not 
alter  the  process  in  one  essential  point,  so  long  as  it  does  not  com- 
pletely suspend  it;  it  only  delays  the  end  by  destruction  of  some 
cells  and  by  the  inhibitive  action  of  toxins  on  others. 

The  Appearance  of  a  Wound  Healing  by  Second  Intention, — At 
tirst,  of  course,  there  is  only  the  raw  surface,  with  more  or  less 
serum  present.  The  various  tissues,  muscle,  fat,  tendons,  fasciae, 
nerves,  and  vessels  are  easily  distinguishable.  On  the  second 
day  the  wound,  if  its  surface  has  not  been  disturbed  by  dressings, 
assumes  a  somewhat  glazed  appearance,  due  to  coagulation  of  the 
albuminous  fluids  on  the  surface;  it  does  not  interfere  with  the 
process,  and  is  prevented  by  dressings.  On  the  third  day  granu- 
1. 1 lion  will  be  noted  on  the  surface;  it  is  covered  densely  by  very 
small  elevations  composed  of  new-formed  cells.  They  are  a  bright 
red  color,  and  have  so  changed  the  appearance  of  the  wound  surface 
that  now  one  tissue  cannot  be  distinguished  from  another,  since 
granulation  tissue  has  covered  them  all  with  a  uniform  hue.  Bone, 
cart  ilage,  and  tendon  do  not  become  covered  so  soon.  Around  the 
edges  will  be  observed  the  faint  bluish-white  line  of  epithelium, 
creeping  inward  from  day  to  day. 

The  steps  of  the  healing  process  all  advance  at  the  same  time;  as 
soon  as  the  field  is  ready  the  fibroblasts  begin  to  form ;  as  soon  as 
they  are  multiplied  into  sufficient  numbers,  the  blood-vessels  grow 
into  them;  as  soon  as  this  is  done,  the  granulation  tissue  begins  to 
be  converted  into  fibrous  tissue;  and  as  soon  as  this  is  old  enough, 
it  begins  to  cicatrize;  so  they  march  from  this  time  on  in  the  order 
named  above,  in  a  tier  from  the  beginning  of  fibroblastic  multi- 
plication to  the  capping  of  the  last  gap  with  epithelium. 

There  is  a  class  of  wounds  healing  by  sennit  I  intention  in  which 
the  depth,  though  sufficient  to  destroy  the  epithelial  covering,  has 
not  destroyed  the  numerous  glands  and  hair-follicles  dipping  down 
into  tin  coriuin.  Such  wounds  are  superficial  brush  wounds,  burns, 
and  frost  -bites  of  the  second  degree,  and  the  wounds  resulting 
from  cutting  Thiersch  skin-grafts.  In  all  this  class  the  epi- 
thelial covering  is  very  quickly  replaced,  due  to  the  islands  of 


74  PRINCIPLES   OF   SURGERY 

epidermization  springing  from  the  mouth  of  every  gland  and  fol- 
licle, as  little  white  dots  in  a  red  sea  of  granulation  tissue.  This 
leaves  little  to  be  done  by  the  surrounding  border  of  epithelium. 
In  these  cases  the  hairs  are  reproduced  and  the  skin  glands  continue 
to  functionate  as  before,  and  the  skin  is  left  ultimately  scarcely 
distinguishable  from  the  surrounding  uninjured  area. 

The  growth  of  scar  tissue  in  large  wounds  healing  by  second 
intention  may,  before  the  process  is  completed,  so  interfere  with  the 
circulation  to  the  granulating  surface  as  to  make  the  rate  of  healing 
tediously  slow,  or  stop  it  altogether,  and  render  the  tissues  it 
contains  an  easy  prey  to  invading  bacteria.  To  prevent  this,  and 
to  be  rid  of  the  slow  process  of  epidermization,  the  surface  may  be 
skin-grafted  in  every  instance  where  it  requires  more  than  a  few 
weeks  for  the  wound  to  cover  in. 

Healing  Under  Scab. — In  the  older  subdivisions  of  the  healing 
process  healing  under  scab  was  given  as  one  type.  It  is  in  no  way 
different  from  healing  by  second  intention.  The  scab,  made  up  of 
dry  discharges,  blood,  serum,  or  pus,  or  a  mixture  of  these,  does 
not  alter  the  process  underneath  in  its  effort  to  meet  the  conditions 
present.  If  there  is  no  infection,  the  scab  serves  to  protect  the 
delicate  granulation  surface  from  injury;  if  there  is  infection* or 
pus,  the  scab  holds  these  beneath  and  the  process  is  retarded 
thereby. 

Healing  by  Third  Intention. — This  is  a  combination  between 
primary  and  secondary  healing.  In  primary  union  the  wound  is 
closed  from  the  beginning;  in  healing  by  second  intention  it  is 
open  throughout  the  whole  period;  in  healing  by  third  intention 
the  wound  is  open  at  least  long  enough  for  granulation  tissue  to 
be  well  under  way,  maybe  much  longer,  and  afterward  these 
granulating  surfaces  are  approximated  and  unite.  Healing  by 
third  intention,  therefore,  is  the  union  of  two  granulating  surfaces. 
As  the  preceding  two  types  have  been  shown  to  be  serviceable  in 
surgical  work,  so  is  healing  by  third  intention.  A  wound  may  not 
be  capable  of  approximation,  owing  to  swelling  or  other  cause; 
when  the  swelling  subsides,  a  few  days  later,  the  surfaces  already 
granulating  are  approximated  by  suture  and  unite.  It  becomes 
necessary  to  drain  a  large  wound;  at  the  time  of  insertion  of  the 
drainage  material  a  provisional  stitch  or  two  is  inserted;  at  the 
end  of  a  few  days  the  drainage,  no  longer  necessary,  is  removed, 
and  the  sutures,  being  tied,  approximate  granulating  surfaces. 
Many  operations  require  to  be  done  at  two  or  three  sittings, 
called  two-time  or  three-time  operations.  By  the  time  the 
surgeon  is  able  to  finish  the  last  step  the  wound  made  at  the  first 
is  healing  nicely  by  second  intention.  It  is  now  closed,  and  heals 
by  third  intention,  otherwise  the  operations  done  at  more  than 


THE  PROCESS  OF  HEALING  75 

one  -it ting  would  in  many  instances  become  unpopular  or  imprac- 
ticable. In  healing  by  third  intention  it  is  necessary  that  the  ap- 
proximation be  well  done,  and  that  infection  be  absent  or  of  such 
mild  grade  that  the  tissues  can  easily  cope  with  it.  If  the  granu- 
lation tissue  is  very  abundant  and  in  the  way  of  accurate  closure 
it  may  be  adjusted  by  cutting  or  curetting.  Granulating  surfaces 
in  contact  with  each  other  soon  adhere  by  a  mechanical  bond  of 
union,  just  as  in  healing  by  first  intention. 

In  the  healing  process  generally,  the  less  the  tissue  is  damaged, 
and  the  less  infection  there  is  present,  the  more  quickly  and  easily 
will  healing  occur.  Infection  and  suppuration  have  no  essential, 
on  t  lie  contrary,  only  a  harmful,  r61e  to  play  even  in  healing  of  open 
wounds,  and  it  is  the  surgeon's  duty  to  protect  these  against 
contamination  as  carefully  as  if  he  expected  primary  union. 

Mention  was  made  at  the  beginning  of  the  discussion  of  the 
healing  process  to  the  effect  that  there  was  one  process  of  healing. 
In  the  following  pages  the  apparent  exception  to  the  rule  will  be 
elucidated.  Suffice  it  to  say  here  that  these  apparent  exceptions 
belong  to  the  regenerative  process  and  take  place  in  connection 
with,  or  subsequent  to,  the  healing  process  without  interfering 
with  the  physiologic  processes  that  create  a  bond  of  union  to 
re-tore  continuity  of  tissue  at  the  site  of  every  wound. 

Healing  of  Nerves. — It  has  been  clearly  stated  already  that 
there  is  one  healing  process,  and  mention  has  been  made  of  the 
apparent  exceptions  of  certain  tissues  of  the  higher  order  which 
are  re-established  in  function  after  section;  of  this  class  the  most 
important  is  the  nervous  system.  The  process  which  re-establishes 
the  histologic  continuity  and  the  function  of  severed  nerves  is  not 
the  process  of  healing.  This  process  performs  a  certain  work,  so 
far  as  bridging  the  gap  made  is  concerned,  and  so  far  as  the  injury 
of  the  adjacent  tissues  may  render  it  necessary,  but  severed  axis- 
cylinders  and  their  sheaths  do  not  reunite;  the  healing  process 
-imply  catches  the  severed  ends  into  a  cicatrix  and  holds  them  there. 
In  fact,  the  more  abundant  the  cicatrix  resulting  from  the  process 
of  repair,  the  less  likely  nerve  function  is  to  be  restored.  Severed 
nerves  do  not  reunite;  if  their  function  is  resumed,  it  is  as  a  conse- 
quence <  .t"  i  letieneration  followed  by  regeneration  of  the  axis-cylinder 
ami  the  white  substance  of  Schwann. 

Section  or  rupture  of  a  nerve  results  in  complete  degeneration 
of  the  nerve-fibers  distal  to  the  point  of  injury,  and  a  similar  de- 
generation of  the  distal  end  of  the  filers  proximal  to  the  injury 
a-  far  as  the  first  or  second  node  of  Ranvier.  This  degeneration 
begins  immediately  and  continues  during  and  after  the  formation 
of  scar  tissue  in  the  damaged  tissues.  After  degeneration  is 
accoinpli-heo!  the  terminal  nodes  of  Hanvier  swell  and  til>ril- 


76  PRINCIPLES   OF   SURGERY 

sprout  out  from  them;  these  fibrils  penetrate  the  newly  formed 
cicatrix  and  enter  the  neurilemma  of  the  old  nerve,  growing  along 
this  as  a  guide  until  nerve-endings  are  established  over  the  original 
ultimate  distribution  with  more  or  less  accuracy  and  function  is 
resumed.  Separation  of  the  severed  ends  and  the  formation  of 
cicatrices  interfere  with,  or  preclude  the  possibility  of,  such  nerve 
regeneration,  and  here  the  distal  end  of  the  proximal  fragment  is 
found  ensheathed  in  a  nodule  of  connective  tissue,  such  as  occurs 
in  amputation  stumps.  When  separation  is  so  wide  that  the  ends 
cannot  be  approximated,  even  after  stretching  the  nerve,  the  in- 
tervention of  a  guide,  such  as  a  segment  of  a  nerve  or  the  inter- 
weaving of  several  strands  of  catgut,  facilitates  the  guidance  of  the 
new-forming  fibers  to  their  destination.  The  avoidance  of  large 
quantities  of  cicatricial  tissue  is  brought  about  in  two  ways:  first, 
by  aseptic  technic;  second,  by  implanting  the  sutured  nerve-ends 
in  a  muscle,  where  the  union  of  the  tissues  about  the  nerve  wound 
will  result  in  the  least  possible  scar  formation.  The  same  end  is 
accomplished  by  ensheathing  the  sutured  nerve  in  a  segment  of  a 
vein  or  similar  material. 

Those  cases  of  nerve  suture,  apparently  resulting  in  immediate 
union,  are  to  be  explained  on  the  ground  that  the  total  nerve 
supply  to  the  part  was  not  severed,  as  is  seen  in  collateral  nerve 
distribution,  where  two  or  more  nerves  send  fibers  to  the  same 
region,  and  in  the  anastomosis  of  nerves  distal  to  the  point  of 
injury. 

The  time  required  for  return  of  function  of  a  severed  nerve 
depends  on  the  distance  the  injury  is  from  the  distribution.  There 
will  be  no  re-establishment  of  function  for  a  few  months  and  many 
months  may  elapse  before  the  process  is  completed.  It  is  but 
reasonable  that  the  shorter  the  peripheral  segment  of  the  nerve 
the  sooner  the  process  of  regeneration  will  be  completed.  The 
functions  do  not  return  simultaneously.  Trophic  action  is  first 
restored,  sensation  follows,  and  lastly  motion.  Complete  restora- 
tion of  function  often  fails;  it  varies  from  total  failure  to  perfect 
physiologic  activity;  wide  separation  of  severed  ends,  infection, 
and  large  cicatrices  reduce  the  chance  of  re-establishing  function. 

One  school  of  neurologists  holds  that  regeneration  takes  place 
from  both  the  proximal  and  the  peripheral  segment,  claiming 
that  there  are  present  in  the  myelin  sheath  neuroblasts,  which, 
when  degeneration  is  finished,  replace  the  axis-cylinder  around 
which  is  formed  the  white  substance  of  Schwann,  and  that  these 
new  peripheral  fibers  unite  with  the  outgrowing  ends  of  the  proxi- 
mal fibers.  Whether  this  be  true  or  false,  it  is  certain  that  after 
avulsion,  in  which  the  total  structure  is  removed,  a  redistribution 
often  takes  place. 


THE    PROCESS    OF    HEALING 


77 


Regeneration  of  Tendon. — Severed  tendons  heal  with  better 
function  if  sutured,  still  the  severed  ends  may  be  separated  some 
ili>tance  without  interference  with  the  result,  provided  immobiliza- 
tion be  maintained.  In  case  the  tendon  sheath  contains  more  than 
one  tendon  it  is  safer  to  do  plastic  lengthening  or  suture.  The 
severed  ends  of  the  tendon  retract  and  the  space  is  filled  with 
blood-clot,  which  surrounds  them  like  a  callus.  It  organizes,  and 
there  appear  in  it  spindle-cells,  which  seem  to  originate  from  the 
inner  surface  of  the  sheath.  These  cells  lie,  for  the  most  part, 
parallel  to  the  tendon  axis.  Beyond  this  the  process  does  not  differ 
from  healing  by  blood-clot.  When  the  process  is  completed  the 
new-formed  tendon  can  scarcely  be  distinguished  from  the  old. 
It  >eem-  that  the  interval  is  filled  by  tendon  regenerated  from  the 
tendon  -he.-ith.  If  this  process  fails,  the  sheath  unites  to  the 


Fig.  2. — Three  fractured  ribs  united  by  an  excessive  callus. 

retracted  cut  ends  within  it.  This  at  times  results  in  fairly  good 
function. 

Regeneration  of  Muscle. — Severance  of  muscle  is  followed  by 
the  development  of  granulation  tissue,  followed  by  cicatrization, 
except  in  so  far  as  it  may  be  replaced  by  muscle-fibers  growing 
into  it  from  either  side.  The  fibers  next  to  these  undergo  longitu- 
dinal division  and  form  new  fibers, 'which  grow  into  the  forming 
cicatrix  from  either  side,  and  meet  and  "interlace  with  one  another 
like  the  tinkers  of  clasped  hands."  If  the  injury  is  small,  the  gap 
may  be  filled  largely  with  new  formed  muscle-fibers;  if  large,  and 
« "-peci.-illy  if  ixxjrly  eoapted,  considerable  quantities  of  the  cica- 
tricial  tissue  remains,  and  only  here  and  there  will  muscle  tissue 
invade  it. 

Healing  of  Bone,  Union  of  Fracture.-  When  the  continuity  of 
Lone  iv  interrupted  the  separated  ends  or  edges  bleed,  and  if,  as 


78  PRINCIPLES   OF   SURGERY 

is  the  rule,  the  surrounding  muscles,  tendons,  and  fasciae  are  in- 
jured, they  contribute  their  quota,  and  a  blood-clot  forms  between 
the  fragments  and  around  them,  extending  well  out  into  the  lac- 
erated tissues.  The  size  of  this  clot  may  be  increased  by  undue 
manipulation  to  elicit  crepitus,  too  often  an  unwarranted  practice, 
or  by  moving  the  patient  without  first  securing  immobility. 

The  periosteum  becomes  thickened  and  vascular  and  loosened 
from  its  bony  attachment  for  a  short  distance  from  the  fractured 
edges.  The  fat  contained  in  the  marrow  at  the  site  of  injury 
disappears  and  a  hyperemia  appears.  Granulation  tissue  is  found 
filling  the  broken  ends  of  the  medullary  canal.  The  clot  is  disposed 
of  by  the  same  absorptive  process  as  in  healing  by  first  intention. 
When  the  granulation  tissue  is  well  under  way,  at  the  expiration 
of  seven  to  ten  days,  the  osteoblastic  cells,  from  the  marrow  that 
has  taken  part  in  the  formation  of  the  granulation  mass,  begin  to 
deposit  bone  in  the  ends  of  the  medullary  canal  and  the  intervening 
space,  producing  an  internal  callus.  All  the  bone  formed  in  the 
healing  of  the  fracture  is  at  first  soft  and  cancellous,  later  harden- 
ing, at  times  until  it  is  denser  than  normal  bone.  At  the  same  time 
the  marrow  cells  begin  to  form  bone,  deposits  of  it  are  also  noted 
at  the  angle  between  the  periosteum  and  bone,  where  separation 
has  occurred.  If  a  periosteal  bridge  is  present  the  same  phenome- 
non may  be  observed  in  the  granulation  tissue  underlying  it. 
Production  of  bones  continues  in  these  two  places,  in  the  medullary 
canal,  and  in  the  mass  of  granulation  tissue  surrounding  the  frag- 
ments until  the  ends  are  held  as  by  a  vise.  So  far  no  ossification 
has  occurred  between  the  cortical  surfaces.  The  surrounding 
cancellous  bone  is  known  as  provisional  callus,  and  its  purpose, 
with  the  internal  callus,  is  to  maintain  the  fragments  in  rigid  fixa- 
tion while  cortical  union  occurs. 

While  the  ensheathing  and  internal  callus  are  forming,  bone 
absorption  is  taking  place  in  the  cortical  portion  of  the  fractured 
ends;  the  bone  becomes  much  less  dense,  the  jagged,  rough  edges 
are  smoothed  down  and  the  granulation  tissue  covers  the  ends  and 
invades  the  intervening  space.  This  is  the  last  productive  step  in 
the  process.  Cancellous  bone  is  formed,  uniting  the  fragments, 
and  gradually  this  is  made  denser  by  deposits  of  bone  from  the 
osteoblasts  which  lie  within  the  cancellous  spaces  until  compact 
bone  is  formed. 

Cartilage  is  observed  at  times  in  the  midst  of  the  granulation 
tissue  as  an  antecedent  of  bone  formation;  it  is  usually  in  small 
quantity  and  is  by  no  means  constant. 

The  new-formed  bone  uniting  the  severed  cortical  portions  is 
called  the  permanent  or  definitive  callus. 

The  internal  callus  is  absorbed  after  perfection  of  the  definitive 


THE    PROCESS    OF    HEALING  79 

callus,  and  the  canal  filled  again  with  marrow.  The  provisional 
callus  likewise  disappears  more  or  less  completely  by  the  action  of 
osteoclasts,  and  the  periosteum  resumes  its  normal  relationship. 
The  accuracy  of  approximation  of  the  fragments  and  perfect  im- 
mobilization have  much  to  do  with  the  size  of  the  permanent  en- 
largement at  the  site  of  fracture.  When  these  two  conditions 
are  complied  with,  there  will  remain  little  or  no  evidence  that  the 
bone  has  been  broken.  Poor  approximation,  angulation,  separa- 
tion of  the  ends,  and  imperfect  immobilization,  if  they  do  not 
result  in  delayed  union  or  non-union,*_will  cause  the  persistence 
of  a  much  larger  callus. 

Under  certain  circumstances,  many  of  them  not  understood, 
the  tissues  seem  unable  to  produce  bony  union,  but  return  to  the 
u>ual  process  of  healing  in  soft  structures,  and  unite  the  thinned 
and  pointed  fragments  by  cicatricial  tissue,  or,  by  an  attempt  at  the 
production  of  a  joint,  or  pseudarthrosis,  in  which  there  appears  a 
capsule,  holding  the  ends  together;  within  this  capsule  is  a  cavity 
containing  a  small  amount  of  serum,  and  the  ends  of  the  frag- 
ments are  covered  with  an  imperfectly  developed  hyaline  cartilage. 
In  other  instances  the  fragments  are  simply  held  together  by  a  cord 
of  fibrous  tissue. 

The  time  required  for  ossification  to  begin  depends  on  the 
patient's  general  condition  and  the  blood-supply  to  the  bone  in 
question  and  the  surrounding  tissue.  In  bones  well  supplied  with 
blood  ossification  begins  by  the  sixth  or  seventh  day;  hi  those 
poorly  supplied,  from  the  tenth  to  the  twelfth  day.  In  the  old  the 
healing  process  does  not  occur  as  readily  as  hi  the  young.  How- 
ever, some  authorities  claim  that  ununited  fractures  are  seen  most 
frequently  during  the  fourth  decade  of  life.  Healing  of  fractures 
likewise  varies  in  time.  Small  bones,  well  supplied  with  blood,  may 
heal  by  the  end  of  fifteen  or  twenty  days.  The  average  time  is 
from  a  month  to  six  weeks,  although  the  definitive  callus  may  not 
fully  form  till  the  expiration  of  several  months. 

SKIN-GRAFTING 

Operations  that  leave  considerable  areas  of  tissue  uncovered  by 
integument,  and  other  surgical  lesions  which  must  heal  by  second 
intention,  are  hastened  materially  by  employment  of  skin-grafts. 
The  amount  of  cicatricial  deformity  is  reduced  to  the  minimum. 
and  in  ulcerative  processes  cure  may  be  seen  from  the  use  of  grafts, 
\\here  failure  or  extensive  deformity  could  only  be  expected  with- 
out them. 

Skin-grafts  are  derived  from  the  individual  on  whom  they  are 
to  be  transplanted,  from  another  individual  of  the  same  species,  or 
from  an  individual  of  another  species.  In  the  first  instance,  they 


80  PRINCIPLES    OF   SURGERY 

are  called  autografts;  in  the  second,  heterografts;  in  the  third, 
zoografts. 

Preparation  of  Field. — When  grafting  is  to  be  done  on  a  newly 
made  wound  the  only  precautions  necessary  are  the  stoppage  of  all 
bleeding,  and  avoidance  of  contact  of  antiseptic  or  other  agents 
harmful  to  the  tissues  with  the  wound  surface.  This  work  must 
be  aseptic,  not  antiseptic.  There  must  also  be  no  torn  and  devi- 
talized shreds  or  pieces  of  tissue  on  the  surface;  it  must  be  mechan- 
ically and  bacteriologically  clean.  When  the  grafts  are  to  be  trans- 
lated to  a  granulating  surface,  all  infection  should  have  disappeared, 
and  the  surface  should  be  covered  with  healthy  granulation  tissue 
and  free  from  pus.  Absolute  freedom  from  infection  is  an  im- 


Fig.  3. — Denuded  surface  ready  for  skin-grafting. 

possibility  here  as  elsewhere,  and  in  many  cases,  if  one  waited  for 
perfect  asepsis,  the  grafting  could  never  be  done;  practically, 
therefore,  the  closest  approximation  to  the  ideal  must  suffice.  The 
field  is  prepared  as  for  any  other  operation;  if  the  grafts  are  to  rest 
on  the  undisturbed  surface  of  the  granulations,  which  may  suffice 
unless  they  are  too  uneven,  no  antiseptic  shall  be  used — it  reduces 
the  chances  of  success.  If  the  surface  granulations  are  to  be 
removed — the  better  plan — the  whole  surface  may  be  treated  with 
antiseptics,  just  as  in  preparation  of  the  skin.  Removal  of  the 
superficial  parts  of  the  granulation  surfaces  and  of  the  unevenness 
may  be  done  by  scraping  with  the  edge  of  a  knife,  by  cutting,  or  by 
the  use  of  a  brush  with  stiff,  small,  closely  set  bristles.  The  latter 
is  far  the  easiest  and  readiest  method,  and,  in  case  it  is  used,  the 


THE    PROCESS    OF    HEALING 


81 


tincture  of  green  soap  and  water  in  contact  with  the  cells  does  little 
injury  if,  indeed,  any.  After  washing,  the  surface  should  be  rinsed 
with  normal  salt  solution  and  the  bleeding  controlled  by  pressure 
and  hot  water,  but  not  hot  enough  to  devitalize  any  cells.  The 
bleeding  controlled,  and  the  surface  dry  and  clean  and  smooth, 
the  grafts  may  be  placed  in  position  according  to  the  method  used. 

Preparation  of  the  field  from  which  the  grafts  are  to  be  taken 
may  be  done  by  any  of  the  methods  for  asepticizing  the  skin.  Here, 
too,  care  must  be  taken  not  to  harm  the  skin  cells  by  vigorous 
chemic  antiseptics,  and  such  as  have  been  used  should  be  thor- 
"Uirhly  washed  from  the  surface. 

In  irrat't  in^  very  large  areas  it  may  be  necessary  to  secure  hetero- 
;  other  condition-  arise  which  make  this  the  more  feasible 


Fig.  4. — Cutting  graft.     Reverdin's  plan. 

plan,  for  example,  the  presence  of  a  skin  disease  in  the  patient. 
Care  must  br  used  in  selecting  the  donor  of  the  grafts,  especially  to 

avoid  the  transmission  of  syphilis. 

Reverdin's  Method. — The  grafts  are  to  be  taken  from  a  well- 
-elected  surface,  usually  the  front  of  the  thigh  or  the  back  of  the 
outer  surface  of  the  arm.  They  are  small  in  size.  \  inch  in  diameter 
approximately,  and  con>i-t  of  cuticle  and  a  small  thickness  of  the 
cutis;  they  are  cut  scarcely  deep  enough  to  bleed  at  most  more  than 
a  drop.  They  may  be  taken  with  or  without  the  administration  of 
6 


82 


PRINCIPLES   OF   SURGERY 


a  general  anesthetic.  This  is  the  only  method  that  can  be  prac- 
tised readily  with  local  anesthesia  or,  in  some  instances,  with  no 
anesthetic.  Cocain  may  be  administered  hypodermically  or  en- 
dermically  in  weak  solution,  or  ethyl  chlorid  may  be  sprayed  on  the 
surface.  The  latter  method  is  too  slow,  and  if  freezing  occurs,  as 
it  must  to  produce  anesthesia,  the  grafts  are  not  so  easily  obtained. 
Pinch  up  a  small  bit  of  the  skin  surface  with  a  pair  of  fine  thumb 
forceps  and  with  scissors  snip  off  the  graft.  It  is  transferred  directly 


Fig.  5. — Placing  graft.     Reverdin's  plan. 

to  surface  of  the  wound  or  ulcer  and  placed  carefully  where  desired; 
press  down  gently  and  guard  against  inversion  of  the  edges  of  the 
graft.  Sometimes  it  is  recommended  that  a  round  needle  or  a 
small  tenaculum  be  stuck  into  the  upper  layers  of  the  skin  and 
lifted  away  from  the  skin,  when  the  grafts  are  to  be  cut  by  scissors. 
This  offers  no  advantage  over  the  use  of  forceps,  and  has  the  ob- 
jection of  allowing  the  graft,  after  cutting,  to  turn  easily  on  its 
hold,  and  is  likely  to  result  in  some  of  them  being  applied  upside 


THE  PROCESS  OF  HEALING  83 

down,  unless  the  most  painstaking  care  be  observed — the  use  of 
smooth  forceps  avoids  this  trouble  and  the  consequent  delay.  The 
grafts  may  be  placed  from  J  to  \  inch  apart,  as  the  individual  opera- 
tor may  choose.  It  is  better  to  place  them  fairly  close  if  possible, 
as  a  goodly  percentage  is  often  lost.  The  value  of  a  very  few  such 
grafts  must  not  be  underestimated,  however,  as  they  spread  over 
considerable  areas,  and  are  valuable  even  when  no  more  than  a 
half-dozen  live. 

After  the  grafts  are  in  position  the  surface  may  be  treated  in 
one  of  two  ways,  namely,  by  placing  a  dressing  in  immediate  con- 
tact with  the  surface,  or  by  dressing  in  such  manner  that  nothing 
touches  the  grafted  area.  The  former  is  carried  out  by  applying 
strips  of  silver  foil  or  gutta-percha  tissue,  aseptic  but  not  anti- 
septic; these  strips  are  cut  narrow,  \  to  f  inch  wide,  owing  to  the 
size  of  the  ulcer,  and  long  enough  to  extend  on  to  the  healthy  sur- 
rounding skin  at  each  end.  They  are  applied  imbricated,  each 


IMK.  6. — Perforated  dressing  for  covering  skin-grafts'. 

overlapping  the  preceding  one,  so  as  to  allow  escape  of  surface  dis- 
charges into  the  overlying  dressing.  If  a  single  sheet  of  material 
he  used  for  covering,  it  must  be  perforated  at  many  points  with 
small  apertures.  The  dressing  applied  must  not  be  bound  tightly 
enough  to  interfere  with  circulation;  the  looser  the  dressing,  pro- 
vided it  is  not  loose  enough  to  slip  and  dislodge  the  grafts,  the 
1  tetter  will  be  the  results.  Another  item  of  importance  is  that 
bulky,  hot  dre-.>ings  should  not  he  used,  as  an  excessive  retention 
of  heat  will  increase  the  number  of  grafts  failing  to  take. 

The  second  method  of  dre—ing  is  preferable  when  feasible.  A 
frame  is  to  be  used  in  >uch  manner  that  the  dressings  do  not  touch 
the  surface.  The  frame  is  fastened  above  and  below  the  wound, 
or  on  all  >ides.  and  the  d re-- ings  applied  over  this  so  that  protection 
and  ventilation  will  he  good,  and  in  sufficient  quantity  to  protect 
against  the  small  amount  of  discharge.  It  is  similar  to  a  vaccina- 
tion -hield  only  on  a  larger  scale. 


84 


PRINCIPLES   OF   SURGERY 


The  dressings  are  not  to  be  removed  for  four  or  five  days.     At 
the  change  of  dressings  the  grafts  have  disappeared  from  view 


Fig.  7. — Imbricated  dressing  for  covering  skin-grafts. 

unless  rather  large.  Later,  they  show  up  as  bluish-white  islands, 
scattered  over  the  red  field  of  granulations,  and  then  rapidly  extend 
until  the  whole  surface  is  covered. 


Fig.  8. — Cutting  a  Thiersch  graft. 

Thiersch's  Method. — In  this  method,  which  is  the  best  under 
ordinary  circumstances,  and  at  the  same  time  capable  of  rapid 


THE    PROCESS    OF    HEALINr, 


85 


execution,  thin  strips  of  the  upper  layers  of  the  skin  are  cut  and 
placed  in  position  so  as  to  cover  the  granulating  or  raw  surface 
entirely.  The  thickness  of  the  grafts  is  sufficient  when  they  include 
the  general  cells  of  the  stratum  papillare. 


Fin.  '.».     Placing  :i  Thirrsch  graft. 

Cuttini;  tfn  drafts. — The  knife  used  should  be  very  sharp  and  not 
hollow  ground  a  ra/or.  a  ratlin,  a  long  bistoury,  or  an  amputating 
knife  will  serve  the  purpose  very  well;  better  satisfaction  will  be 
had  if  the  bla<le  i-  fixed  immovably  to  the  handle.  The  chief  ob- 
jection to  u>ing  an  ordinary  razor  is  the  difficulty  arising  from  the 


86  PRINCIPLES   OF   SURGERY 

movable  handle.  The  skin  from  which  the  grafts  are  cut,  usually 
the  anterior  surface  of  the  thigh  or  the  outer,  anterior,  or  posterior 
surface  of  the  arm,  must  be  sterilized  and  shaved  unless  the  hair 
be  rudimentary.  The  skin  is  now  rendered  tense  by  skin  hooks 
placed  at  each  extremity  of  the  surface  from  which  the  grafts  are 
to  be  cut,  or  by  holding  the  skin  taut  with  the  hands  or  by  other 
device.  As  the  cutting  is  done  the  graft  folds  itself  on  the  surface 
of  the  knife  if  the  blade  is  broad  enough,  and  may  be  transferred 
directly  to  the  surface  to  be  covered.  This  process  will  be  re- 
peated until  enough  cutis  is  obtained  to  cover  the  whole  area. 

Placing  the  Grafts. — The  surface  of  the  wound  or  ulcer  must  be 
prepared  just  as  described  in  Reverdin's  method,  all  oozing  checked, 
and  all  clots  removed  from  the  scraped  surface.  If  bichlorid  of 
mercury  is  used  it  must  be  followed  by  abundant  irrigation  with 
warm  salt  water  solution;  it  will  hardly  be  necessary  to  use  anti- 
septics on  the  granulating  surface,  as,  if  the  infection  present  be 
sufficient  to  demand  it,  it  will  be  time  well  spent  to  combat  the 
infection  a  few.  days  longer  before  grafting.  It  requires  but  little 
judgment  to  understand  that  infection  of  the  surface  will  cause 
disintegration  of  the  clotted  serum  which  forms  between  the  graft 
and  the  surface  it  covers,  just  as  the  mechanical  bond  of  union  of 
wounds  healing  by  first  intention  is  destroyed  by  infection,  and  the 
grafts  die.  If  any  accumulation  of  fluid  is  noticed  lifting  some 
parts  of  the  grafts  up  from  the  surface,  it  must  be  gently  pressed 
out,  so  that  they  may  lie  in  closest  contact  with  the  subjacent 
structures. 

The  grafts  are  to  be  placed  so  that  they  overlap  the  edge  of  the 
surface  surrounding  the  wound  or  ulcer;  they  must  be  placed  exactly 
in  contact  with  each  other  along  their  edges,  or  they  may  slightly 
overlap ;  every  precaution  is  taken  to  prevent  their  edges  from  curl- 
ing under,  as  no  "take"  will  be  had  at  such  points.  This  tendency 
to  curl  under  is  the  chief  objection  to  running  the  grafts  through  a 
normal  salt  solution  at  or  slightly  above  body  temperature, 
although  this  immersion  in  the  solution  does  not  interfere  with  the 
vitality  of  the  flaps  or  the  success  of  the  work.  It  even  becomes 
necessary  to  use  the  salt  solution  in  those  cases  where  work  is  done 
with  unskilled  assistants,  and  where,  owing  to  the  location  of  the 
ulcer,  direct  transfer  of  autogenous  flaps  cannot  be  done. 

During  the  cutting  of  heterogenous  grafts  the  donor  should  be 
anesthetized,  preferably  with  nitrous  oxid. 

Dressings. — The  dressings  most  useful  here  are  the  same  as 
those  described  under  Reverdin's  method.  However,  failure  to 
have  the  necessary  material  at  hand  should  not  deter  one  from 
utilizing  this  method,  as  most  satisfactory  work  may  be  done  by 
applying  fluffed  iodoform  or  plain  gauze,  which  is  to  be  strapped 


THE    PROCESS    OF    HEALING  87 

down  with  adhesive  plaster  to  prevent  gliding,  and  then  covered 
with  adequate  quantities  of  gauze  or  cotton  and  bandaged  in. 
This  point  must  be  remembered,  namely,  that  too  early  change  of 
the  gauze  lying  next  to  the  grafts  endangers  success;  this  gauze, 
therefore,  lying  under  the  adhesive  straps  should  not  be  removed 
until  the  expiration  of  seven  to  twelve  days,  and  then  cautiously 
after  throughly  saturating  with  salt  solution.  Of  course,  if  local 
or  constitutional  conditions  demand  their  removal,  the  possible 
sacrifice  of  the  grafts  must  be  accepted. 

Wolfe's  Method. — As  Reverdin's  method  utilized  only  small 
l>it<  of  skin  from  the  surface,  and  Thierscb's  method  large  pieces  of 
cuticle,  so  Wolfe's  method  employs  the  whole  thickness  of  the  skin 
cut  in  such  shape  and  of  such  size  that  it  will  fit  as  accurately  as 
possible  the  area  to  be  covered.  The  same  antiseptic  and  aseptic 
precautions  are  to  be  used  here  as  in  the  preceding  two.  The  same 
preparation  of  the  granulating  surface  is  to  be  done  and  the  hemor- 
rhage must  be  controlled  absolutely.  The  additional  provision 
of  rendering  the  edges  of  the  ulcer  or  wound  vertical  and  smooth 
should  be  made  to  prevent  unevenness  at  the  border  of  contact. 
The  graft  is  to  be  cut  somewhat  larger  than  the  area  to  be  covered, 
for  contraction  of  the  graft  will  reduce  it  to  two-thirds  or  three- 
fourths  its  size  before  excision.  Only  the  skin  is  to  be  taken;  sub- 
cutaneous fat  and  fascia  are  not  desirable,  and  if  abundantly  pres- 
ent will  be  the  cause  of  failure.  The  utmost  care  must  be  exercised 
not  to  bruise  the  skin  during  preparation,  and  the  gentlest  dissec- 
tion possible  to  avoid  injury  during  excision  of  the  graft. 

Wolfe's  method  offers  much  less  chance  of  success  than 
Thiersch's  or  Reverdin's  method;  but  when  circumstances  arise 
such  that  the  contraction  which  comes  to  a  certain  extent  with  the 
ahove-named  methods  would  interfere  either  with  the  cosmetic 
result  or  more  especially  with  the  practical  usefulness  of  the  part, 
a-  in  eases  where  the  skin  has  been  lost  from  the  palm  of  the  hand 
or  the  sole  of  the  foot,  then  Wolfe's  method  deserves  trial,  and 
repetition  of  it  if  necessary.  The  edges  may  be  sutured  to  the 
surrounding  skin  or  may  be  held  in  place  by  gentle  uniform  pres- 
sure. It  cannot  l>e  too  strongly  emphasized  that  heavy  pressure 
and  gliding  of  the  grafts  are  certain  to  preclude  union. 

A'/v/i/.sr's  Method, — Another  method  makes  use  of  the  total 
thickness  of  the  skin.  The  avoidance  of  injury,  the  careful  dis- 
section, the  use  of  no  subcutaneous  tissue,  and  the  vertical  section 
of  the  skin  surrounding  the  site  of  grafting  hold  as  in  Wolfe's 
method:  here,  however,  the  skin  is  cut  in  long  narrow  strips  from 
the  thigh,  hack,  or  arm,  and  allow-  easier  closure  of  the  wound. 
These  strips  are  placed  side  hy  side  until  the  breach  is  covered. 
They  are  not  sewn.  hut.  if  >uc< •.—  ful,  soon  adhere  at  their  adjacent 


88 


PRINCIPLES   OF   SURGERY 


borders.  In  both  the  Wolfe  and  the  Krause  method  the  graft 
becomes  cyanotic  and  loses  its  epidermis.  As  the  circulation  is 
established  they  gradually  assume  their  normal  color.  Infection 
renders  either  of  these  methods  fruitless.  Great  care  should  be 
exercised  not  to  bruise  the  skin  during  preparation,  and  the 
gentlest  dissection  possible  must  be  done  to  avoid  injury  during 
excision  of  the  graft. 

BONE-GRAFTING  OR  TRANSPLANTATION 

Besides  skin-grafting,  the  most  useful  and  most  widely  ap- 
plicable transplantation  of  tissue  is  that  of  bone,  which  is  done  to 
replace  deficient  bone  or  to  establish  bony  tissue  where  it  is  entirely 
wanting. 

The  sources  of  bone-grafts  may  be  the  patient's  own  tissue, 
the  amputated  or  excised  bone  of  other  human  subjects,  or  of  the 
lower  animals.  The  grafts  may  be  used  in  the  form  of  a  number 


Fig.  10. — Tibia  from  which  a  bone-graft  has  been  cut. 

of  small  pieces,  bone-chips,  or  as  a  single  specimen  of  sufficient 
size.  They  may  be  used  fresh  or  dried,  and  with  or  without 
previous  sterilization  by  boiling,  but  they  must  be  aseptic.  They 
may  be  placed  in  position  at  the  time  the  defect  is  made ;  if  the 


Fig.  11. — Bone-grafting. 

bacterial  conditions  are  favorable,  this  is  the  better  course ;  if  not, 
then  at  some  suitable  subsequent  sitting.  They  may  be  used  to 
replace  the  whole  thickness  of  bones,  as,  for  example,  the  tibia 
after  resection,  or  they  may  only  fill  out  a  partial  defect.  They 
may  be  held  in  position  by  nailing  with  ivory  pegs,  such  as  are  used 
in  the  immobilization  of  fractures,  or  held  by  the  tissues,  if  the 


THE    PROCESS   OF   HEALING  89 

bone  continuity  has  not  been  interrupted,  by  the  mechanical  de- 
vices useful  in  the  treatment  of  fractures,  or  the  graft  may  be  set 
in  a  socket  in  the  fragment  at  each  end. 

The  success  of  lx>ne-grafting  depends  on  the  perfect  cleanliness 
of  technic;  it  is  the  process  of  healing  by  blood-clot  in  which  the 
sterile  bone  is  to  become  encysted,  and  failure  of  asepsis  will  pro- 
duce the  same  clinical  manifestations  as  those  seen  in  necrosis  of 


Fig.  12. — Bone-grafting. 

bone  and  the  same  pathologic  result,  namely,  destruction  of  the 
included  portion  of  dead  bone. 

The  process  of  repair  of  defective  bone  is  utterly  unlike  that  of 
skin-grafting — in  the  latter  the  graft  lives  and  grows;  in  the  former 
the  graft  may  be  dead  to  begin  with  or,  if  not  dead,  it  may  die,1  and 
is  dealt  with  by  the  tissues  as  any  other  foreign  substance  buried 
in  them,  by  being  absorbed  as  much  as  possible,  and  by  being  sur- 
rounded and  penetrated  by  the  tissue  formation.  The  earthy 
material,  however,  remains,  and  serves  as  a  framework  of  the  new 


Fig.  13. — Bone-grafting. 

bone  to  be  built  on  the  ruins  of  the  old.  The  presence  of  such 
earthy  material  stimulates  the  deposit  of  similar  new  material  and 
a.oun--  the  formation  of  bone  instead  of  the  usual  cicatrix. 

The  length  of  time  requisite  for  completion  of  the  process 
depends,  necessarily,  on  the  size  of  the  fragments  and  the  activity 
of  the  process;  it  is  more  rapid  when  fresh  hone  is  transplanted  than 
in  the  cases  where  dried  bone  is  used;  likewise,  it  is  more  rapid 
when  periosteum  can  be  brought  to  cover  the  grafts  more  or  less 

1  Thoro  can  be  no  doubt  that  some  bone-gnifta  do  not  lose  thoir  vitality 
altogether. 


90  PRINCIPLES   OF   SURGERY 

completely,  or  when  the  graft  carries  its  own  periosteum  and  mar- 
row. The  time  required  for  immobilization  should  be  governed  by 
the  rules  for  fractures  at  the  point  under  treatment  and  should  be 
even  longer. 

In  defects  due  to  various  diseases  affecting  the  bones  destruc- 
tively, such  as  osteomyelitis  and  caries,  and  hi  those  where  resec- 
tion of  the  bone  has  become  necessary  as  a  result  of  tumor  for- 
mation, the  results  obtained  from  bone  transplantation  are  very 
satisfactory. 

Mucous  Membrane. — Transplantation  of  mucous  membrane, 
very  similar  in  the  entire  details  to  skin-grafting,  but  requiring 
much  more  delicate  work,  is  useful,  especially  in  eye  surgery.  The 
grafts  are  obtained  from  lower  animals,  usually  the  rabbit. 

Grafting  of  Other  Tissues. — Transplantation  of  muscles,  ten- 
dons, and  nerves  has  usually  a  different  meaning  from  the  appli- 
cation of  the  term  as  used  above.  In  these,  the  suturing  of  a  ten- 
don, nerve,  or  muscle  to  a  new  attachment  is  done  without  severing 
it  from  its  vital  connections  in  the  body.  Thus,  a  tendon  may  be 
transferred  from  a  posterior  to  an  anterior  insertion,  and  the  muscle 
be  thus  converted  from  a  flexor  into  an  extensor;  or  a  nerve  that 
supplied  a  certain  group  of  muscles  be  severed  and  united  to  the 
distal  portion  of  one  whose  center  has  failed,  and  a  sacrifice  of  the 
first  group  be  made  to  re-establish  function  in  the  more  important 
group;  however,  tendons  and  nerves  may  be  easily  and  success- 
fully transplanted  to  fill  out  the  spaces  left  by  destruction  of  these 
tissues.  Fascia  is  also  transplanted  with  the  most  flattering  suc- 
cess, as  may  be  illustrated  by  the  transplantation  of  the  dense  fascia 
of  the  outer  surface  of  the  thigh  to  correct  defects  in  cases  of  hernia. 

Blood-vessels  may  be  grafted  with  success,  thanks  to  the  recent 
investigations  of  vascular  surgery,  by  suturing  a  segment  between 
the  severed  ends  of  an  injured  vessel,  and  the  thyroid  gland  may, 
with  some  degeee  of  success,  be  transplanted  into  the  body  of 
patients  suffering  from  hypothyroidism.  So  far  it  seems  impossible 
to  make  the  engrafted  gland  continue  its  function  indefinitely. 

Various  other  materials  are  used  in  the  correction  of  bodily 
defects,  but  they  depend  for  their  efficacy  on  a  permanent  mechan- 
ical support,  and  in  no  way  are  replaced  by  living  tissue,  remaining 
as  encysted  foreign  bodies,  subject  to  the  dangers  of  such. 

Transplantation  of  entire  organs,  such  as  kidneys,  has  been 
performed  experimentally,  but  has  as  yet  assumed  no  practical 
value,  for,  while  a  more  or  less  perfect  function  may  be  established 
and  maintained  for  a  time,  failure  comes  after  a  few  months  and 
atrophy  and  loss  of  the  engrafted  organ  follows. 


CHAPTER  IV 
INFLAMMATION 

Definition. — Inflammation  is  the  response  of  living  tissue 
through  the  blood-vessels  and  the  blood  to  an  irritant,  by  means 
of  \\hich  an  attempt  is  made  to  remove  that  irritant,  to  limit  its 
>pread  or  action,  and  to  repair  the  damage  done  by  it. 

It  can  be  seen  by  close  study  of  the  above  definition  that  the 
inflammatory  process,  instead  of  being  a  diseased  condition,  is  an 
effort  called  forth  by  adequate  cause  for  the  purpose  of  correction 
of  defects  produced,  or  the  prevention  of  lesions  that  would  of 
-ity  follow  if  no  intervention  were  made.  It  is  a  curative,  a 
n  'punitive  process,  and  must  be  looked  upon  as  such,  both  from  the 
standpoint  of  pathology  and  therapy,  the  real  disease  being  the 
irritant.  The  definition  above  does  not  embrace  the  secondary 
parts  played  by  the  nervous  system  or  by  the  various  tissues  in 
which  the  process  may  appear;  these  facts  will  be  developed  as  we 
proceed. 

The  nature  of  the  irritant  active  in  the  production  of  inflamma- 
tiitu  i-  usually  chemic,  and  may  be  either  an  organic  compound, 
which  is  practically  always  the  case,  or  inorganic.  If  non-chemic 
agents  serve  as  the  cause  of  inflammation,  it  can  scarcely  be  con- 
sidered as  being  more  than  the  healing  process. 

Termination  "Itis." — The  termination  "itis"  is  used  in  medical 
literatim-  to  signify  inflammation,  the  structure  affected  by  the 
process  heing  indicated  by  the  word  to  which  "itis"  is  appended. 

Thi-  termination  is  suffixed  to  the  names  of  tissues,  and  then 
signifie-  inflammation  of  those  tissues  without  reference  to  the 
part  of  the  body  so  affected.  So  adenitis  signifies  inflammation  of 
lymph-nodes;  myositis,  inflammation  of  muscles;  osteitis,  inflam- 
mation of  bone;  cellulitis,  inflammation  of  cellular  or  connective 
ti-- ue;  with  no  reference  in  either  instance  to  the  particular  nodes, 
mu-clex.  or  connective  tissue  affected. 

"Iti-"  i-  Minilarly  appended  a-  a  -utiix  to  the  names  of  organs 
or  other  anatomic  entities,  as  appendicitis,  inflammation  of  the 
vermiform  appendix;  hepatitis,  inflammation  of  the  liver;  vaginitis, 
inflammation  of  the  vagina;  stomatiti-.  cv>titi-.  nephritis,  and  so 
on.  Hut  here  no  indication  i-  given  of  the  particular  part  or  tissue 
of  these  structure-  involved,  unless  further  specified. 

Terms.  It  i-  wi-e  here  to  give  a  number  of  term-,  u-ed  a- 

91 


92  PRINCIPLES   OF   SURGERY 

descriptive  of  the  inflammatory  process,  as  they  are  employed  in 
medical  parlance.  They  are  classified  into  groups  for  convenience 
of  study,  but  must  not  be  considered  as  a  classification  of  the  in- 
flammatory processes,  since  many  of  these  terms  might  with  pro- 
priety be  applied  to  the  same  condition  at  one  time,  and  since  some 
of  them  are  of  questionable  propriety. 

Relative  to  Cause. — (1)  Infective.  This  term  denotes  an  in- 
flammatory process,  the  cause  of  which  is  an  infection  with  at  least 
one  species  of  pathogenic  bacteria.  The  term  has  additional  sig- 
nificance, in  that  the  inflammatory  process  may  be  induced  in  other 
tissues  by  accidental  transfer  of  the  bacteria  producing  it. 

(2)  Traumatic  inflammation  signifies  that  trauma,  or  injury, 
is  the  cause  of  the  condition.     Trauma  is  usually  accepted  as  only 
the  predisposing  cause,  yet,  since  the  injury  so  reduces  the  vitality 
of  the  tissues  as  to  render  them  more  easily  susceptible  to  bacterial 
ravages,  the  term  is  admissible  if  thus  understood. 

(3)  Sympathetic  inflammation  is  used  to  indicate  that  a  cause 
of  inflammation  may  be  found  in  the  nerve-supply  of  the  part. 
Irritation  of  the  periphery  of  a  nerve  may  so  affect  another  tissue, 
supplied  by  a  different  branch  of  the  nerve,  or  by  a  nerve  whose 
center  is  in  close  functional  relation  to  its  own,  as  to  predispose  to  or 
produce  an  inflammation  of  the  structures  supplied  by  the  second 
branch  or  nerve.    The  most  notable  example  of  this  is  sympathetic 
ophthalmia. 

(4)  Neuropathic  inflammation,  closely  allied  to  sympathetic, 
means  that  from  some  disturbance  of  innervation,  whether  it  arises 
from  central  or  peripheral  causes,  a  reduction  of  the  vitality  of  a 
part  may  arise  to  the  extent  of  favoring  the  least  exciting  cause. 

(5)  Hypostatic  inflammation  is  produced  by  the  accumulation 
of  blood  in  a  part  due  to  its  dependent  position  and  the  inability 
of  the  heart  to  drive  the  blood  actively  through  it;  this  stagnation 
of  blood  is  nothing  more  than  a  passive  congestion;  the  failure  to 
get  a  proper  supply  of  blood  reduces  the  resistance  of  the  tissues 
and  they  are  then  easily  attacked. 

Relative  to  Duration. — (1)  Acute  inflammation  signifies  that  the 
process  has  arisen  within  a  short  period  of  time,  a  few  hours  or 
days,  and  usually  runs  a  short  course,  and  subsides  within  a  few 
days  or  a  few  weeks  at  most,  unless  it  becomes  either  subacute  or 
chronic. 

(2)  Fulminating  inflammatory  processes  may  be  described  as 
very  rapid  in  development  and  violent  in  activity.     The  develop- 
ment of  this  type  occupies  usually  only  a  few  hours.     It  is  hyper- 
acute. 

(3)  Chronic  inflammation  means  one  of  long  duration.     It  may 
have  originated  as  an  acute  process  and  become  chronic,  or  it  may 


INFLAMMATION  93 

be  of  such  nature  at  the  beginning  that  its  chronicity  is  recognized 
t  hen.  It  lasts  for  months  or  years.  The  symptoms  and  signs  are 
usually  less  marked  than  in  acute.  It  is  not  unusual  to  see  acute 
exacerbations  of  chronic  inflammatory  processes;  this  is  due  to 
trauma,  or  other  accident,  or  to  secondary  infection. 

(4)  Subacute  is  sometimes  used  to  signify  an  inflammation  in- 
termediate between  acute  and  chronic. 

Relative  to  Activity. — (1)  Sthenic  inflammation  is  a  very  active 
process,  with  marked  local  and  constitutional  symptoms.  It  is 
the  type  seen  in  robust,  vigorous  individuals,  and  may  be  said  to 
l>e  an  excessive  reaction  to  the  poison  invading  the  body.  A 
good  example  is  lobar  pneumonia  as  it  appears  in  strong  and  vigor- 
ous  men,  with  high  temperature  and  slow,  full,  bounding  pulse. 

(2)  Asthenic  inflammation  is  the  very  opposite  of  the  latter. 
It  occurs  in  those  whose  bodily  vigor  is  unequal  to  the  demands, 
and  in  those  who  are  overwhelmed  by  the  poisons  absorbed  and 
whose  symptoms,  while  less  marked,  are  often  more  alarming. 
In  this  type  there  is  usually  a  lowered  temperature  and  a  rapid, 
feeble  pulse.  The  term  asthenic  conveys  the  idea  of  exhaustion. 

Relative  to  the  Tissue  Involved. — (1)  Parenchymatous  inflamma- 
tion attacks  the  functionating  cells  of  an  organ,  the  parenchyma. 
The  chief  value  of  this  distinction  lies  in  the  fact  that  if  the 
parenchyma  of  vital  organs  be  attacked  by  an  inflammatory  proc- 
B0S,  their  failure  to  functionate  for  a  time  may  produce  grave  or 
even  fatal  results.  An  illustration  of  parenchymatous  inflamma- 
tion is  acute  parenchymatous  nephritis. 

(2)  Interstitial  inflammation  signifies  that  the  connective  tissue 
of  an  or<;aii  is  attacked.     Illustration,  interstitial  nephritis. 

(3)  Diffuse  inflammation,  while  used  loosely,  has  the  special 
significance,  as  applied  to  organs,  of  inflammation  of  the  total 
structure,   rnibracing,  therefore,  both  the  parenchyma  and  the 
connective-tissue  framework.     The  term  is  also  loosely  employed 
to  signify  a  widely  spread  inflammation,  as  of  the  skin  or  perito- 
neum. 

(4)  Serous  inflammation  means  that  affecting  any  serous  mem- 
brane. 

(5)  Catarrhal  inflammation.     Catarrh  is  inflammation  of  the 
mucou>  membrane.     It  is  not  different  from  the  inflammatory 
process  elsewhere,  except  for  the  structure  attacked.     The  char- 
acteristic giving  it  the  name  is  the  free  discharge  of  mucus  or 
muoopciB. 

l;>  lutirr  to  the  Product. — (1)  Plastic,  adhesive,  fibrinous,  or 
fibrinoplastic  inflammation  always  occurs  on  a  serous  surface  and 
is  characterized  by  the  deposit  of  fibrin.  This  fibrin  may  simply 
cover  the  surface  as  a  fal>e  membrane,  or,  if  two  surfaces  lie  in 


94  PRINCIPLES   OF   SURGERY 

contact,  it  seals  them  together,  forming  an  additional  barrier 
to  the  advance  of  the  causative  infection,  and  preventing  a  free 
esqape  of  infected  fluids  from  the  primary  focus  into  the  surround- 
ing cavity ;  it  thus  becomes  the  chief  means  of  early  limitation  of  an 
infection  in  serous  cavities,  especially  in  the  peritoneum.  If  the 
inflammatory  process  is  very  rapid  there  is  often  no  evidence  of 
fibrin  deposit  and  unlimited  spread  of  the  infection  is  possible. 
The  fibrinous  deposit  is  usually  largely  or  entirely  disposed  of  if 
the  offending  organ  is  properly  dealt  with  early;  if  not,  it  later  be- 
comes organized  into  fibrous  tissue  and  remains  permanently, 
capable  of  later  disturbance  by  interfering  with  peristalsis  or  pro- 
ducing intestinal  obstruction,  or  causing  malposition  of  viscera  in 
the  abdomen,  fixation  of  the  lung,  and  limitation  of  the  breathing 
capacity  in  the  pleura,  or  ankylosis  in  the  joints. 

Plastic  deposits  invariably  follow  drainage  of  the  abdominal 
cavity,  whether  infection  is  present  or  not,  but  they  are  usually 
absorbed. 

(2)  Purulent  or  suppurative  inflammatory  processes  are  those 
in  which  pus  is  produced.     They  may  be  manifestly  suppurative 
in  certain  instances,  while  in  others  it  may  require  the  utmost 
vigilance  to  determine  this  point. 

(3)  Croupous  or  diphtheric  inflammation  is  an  inflammatory 
process  attacking  mucous  membranes,  on  the  surface  of  which  a 
false  membrane  of  a  fibrinous  nature  is  deposited.     This  membrane 
may  be  separated  from  the  mucous  surface  on  which  it  forms,  or 
may  become  dislodged  in  the  course  of  the  disease  causing  it,  and 
give  trouble.     Croupous  inflammation  is  found  more  often  affect- 
ing the  pharynx,  the  upper  air-passages,  and  the  larynx  and  trachea. 
Pathologically,  no  important  distinction  can  be  made  between 
croupous  and  diphtheric  membranes,  although  a  constantly  di- 
minishing number  of  physicians  claim  a  clinical  distinction,  in 
that  the  membrane  of  a  croupous  inflammation  may  be  separated 
from  the  underlying  mucous  membrane,  leaving  the  latter  intact, 
while  the  membrane  of   a  diphtheric    inflammation    cannot  be 
removed  without  taking  with  it  the  upper  layers  of  the  mucous 
membrane  which  were  incorporated  during  the  period  of  formation 
of  the  false  membrane,  and  thus  the  mucous  surface  is  left  raw  and 
bleeding.     The  difference  is  considered  chimeric  by  pathologists, 
and  may  be  dismissed  as  useless,  either  in  a  clinical  or  pathologic 
way. 

(4)  Gangrenous  inflammation  is  sometimes  loosely  used  to 
signify  an  inflammatory  process  which  has  terminated  in  the  death 
of  more  or  less  tissue,  and  is  of  value  only  because  it  indicates  that 
the  process  is  violent,  as  in  fulminating  processes,  or  that  the 
resistance  is  poor,  as  seen  in  asthenic  cases. 


INFLAMMATION  95 

(5)  Proliferative  inflammation  indicates  that  new  tissue  has 
formed,  or  is  forming,  as  a  result  of  chronic  inflammatory  changes. 
Tin-  may  easily  result  from  plastic  processes,  in  which  the  fibrin- 
ou-  exudate  is  maintained  until  its  organization  into  fibrous  tissue 
and  permanent  adhesions  made  up  of  living  connective  tissue  result. 
Proliferative  inflammation  is  found  in  chronic  interstitial  nephritis, 
inn  1 1  he  new-formed  connective-tissue  contracting  causes  the  kidney 
to  become  smaller  hi  size,  and  thus  sacrifices  the  functionating 
portion  to  the  proliferative  results  of  an  old  inflammation.     So, 
again,  this  type  may  be  seen  affecting  joints  which  have  long  been 
inflamed  and  maintained  immobile  by  virtue  of  the  disease,  or  as  a 
plan  of  treatment,  and  ankylosis  be  established  by  the  new  tissue. 
This  may  be  illustrated  again  in  the  effects  of  inflammation  on 
bone  and  bone-producing  cells,  only  here  the  new  tissue  is  osseous, 
and  a  bone  whose  periosteum  has  been  long  inflamed  may  more  than 
double  its  diameter. 

(6)  Moist  inflammation  is  seen  on  mucous  surfaces  and  indi- 
cates simply  that  there  is  a  discharge,  watery,  mucous,  or  muco- 
purulent  in  character. 

(7)  Dry  inflammation  indicates  that  there  is  no  discharge,  and 
has  reference  to  the  mucous  membrane  as  the  antithesis  of  moist 
inflammation. 

(8)  Hemorrhagic,  hi  which  there  is  a  tendency  to  bleed,  as  hi 
acute  pancreatitis. 

!,'>  Intire  to  the  Course. — (1)  Healthy  inflammation  indicates 
that  the  inflammatory  process  is  running  a  satisfactory  course  to 
recovery.  The  term  is  ill-advised  and  but  little  used,  since  the 
very  presence  of  inflammation  would  suggest  disease  rather  than 
otherwise. 

(2)  Unhealthy  inflammation  is  one  running  an  unsatisfactory 
course  and  showing  signs  of  evil  tendencies. 

(3)  Latent  inflammation  is  one  which  has  run  its  course  without 
sufficient  clinical  evidence  to  warrant  a  correct  diagnosis,  and  per- 
haps  has  caused  little  or  no  inconvenience  to  its  host.    Such  in- 
flammatory processes  often  run  on  until  the  hope  of  cure  is  lost 
before  an  attempt  is  made  to  learn  the  cause  of  trouble.     They  are 
n-iially  chronic,  and  Bacillus  tuberculosis  stands  at  the  head  of  the 
li-t  a.-  the  cause  of  them. 

Etiology  of  Inflammation. — The  causes  of  inflammatory  changes, 
wherever  they  may  occur,  are  very  definite,  though  they  may  not 
be  patent  in  a  specific  case.  They  are  subdivided  into  predis- 
po.-ing  and  exciting.  It  is  appropriate  here  to  make  it  clear  that 
the  predi-po-ing  causes  cannot  of  themselves  excite  a  true  inflam- 
mation: that  the  exciting  causes  may  l>e  present,  and  fail  to  pro- 
duce inflammation  unle-s  the  predi.-posing  causes  have  first  pre- 


96  PRINCIPLES   OF   SURGERY 

pared  the  way;  finally,  that  the  exciting  causes  may  be  in  certain 
instances  so  potent  to  produce  inflammation  as  never  to  fail, 
whether  a  single  predisposing  factor  has  been  present  or  not. 

Predisposing  Causes. — This  embraces  all  factors  that  reduce  the 
resistive  powers  of  the  body  to  onslaughts  from  agencies  which 
demand  an  inflammation  for  then-  relief  or  removal.  These 
predisposing  factors  may  pertain  to  the  whole  body  or  to  some 
organ  or  part  which  is  influenced  deleteriously,  while  the  body  as 
a  whole  may  remain  free  from  their  influence. 

(1)  Deficiency  in  the  Quantity  of  Blood  (Oligemia). — Whatever 
may  be  the  nature  of  the  cause  that  reduces  the  total  quantity  of 
blood  in  the  body  sufficiently  to  make  an  impression  on  the  func- 
tion of  any  or  all  the  component  structures,  the  blood  becomes  less 
efficient  along  the  lines  of  antibacterial  resistance,  and,  by  so  doing, 
makes  easier  the  invasion  of  the  tissues  by  the  exciting  causes  of 
inflammation.  This  may  be  a  general  anemia  resulting  from  hem- 
orrhage, as  is  seen  in  cases  of  tuberculosis  pulmonalis,  in  post- 
partum  hemorrhage  or  any  bleeding  from  any  surgical  condition, 
such  as  traumatism,  postoperative  bleeding,  or  that  from  ulcerated 
malignant  tumors.  The  cause  or  source  of  the  hemorrhage  is 
non-essential;  the  important  fact  is  that  hemorrhage  shall  have 
occurred  in  extensive  quantity. 

Deficiency  in  the  quantity  of  blood  is  also  a  result  of  prolonged 
and  exhaustive  diseases,  as  typhoid  fever  independent  of  hemor- 
rhage, or  in  tuberculosis  and  syphilis  if  improperly  treated.  The 
failure  of  the  blood-making  organs  to  manufacture  it  in  keeping 
with  the  demand  results,  by  slow  stages,  in  the  same  reduction  of 
the  volume  of  blood  as  hemorrhage  does  in  a  brief  period. 

The  reduction  in  the  quantity  of  blood  may  be  purely  a  local 
matter,  and  serve  the  same  end  for  the  part  concerned  as  if  the 
total  volume  of  blood  were  reduced  to  the  same  degree.  This 
local  condition,  in  its  broad  sense,  means  that  an  insufficient 
quantity  of  blood  is  circulating  through  the  vessels  of  the  part, 
whether  from  arterial  obstruction,  which  does  not  permit  the 
blood  to  pass,  and  leaves  the  vessels  distal  to  the  obstruction 
incompletely  filled  or  filled  only  as  an  inadequate  collateral  cir- 
culation may  afford,  or  from  a  venous  obstruction,  which,  while 
it  keeps  the  vessels  overdistended  continuously,  yet  does  not 
permit  the  blood  to  return  to  the  heart  and  lungs  with  sufficient 
rapidity  to  maintain  its  normal  state.  Both  factors  can  be  opera- 
tive at  the  same  time. 

Obstruction  to  the  circulation  is  especially  due  to  the  pressure 
of  tumors  on  the  vessels,  to  thrombus  and  embolus,  and  to  liga- 
tures applied  in  continuity.  Thrombi  are  produced  avoidably 
by  injury  to  the  veins  during  operation  or  by  undue  traction  on 


INFLAMMATION  97 

them,  especially  in  the  abdominal  cavity,  and  by  improper  post- 
operative treatment  of  surgical  cases,  especially  if  that  surgery 
is  done  in  the  pelvis.  Ligatures  applied  to  veins  or  arteries  must  be 
so  placed  if  possible  to  allow  the  best  collateral  circulation,  and 
ought  to  be  applied  with  the  least  possible  separation  of  the 
vascular  sheaths  from  the  vessels  and  consequent  rupture  of  the  vasa 
vasorum.  This  observation  is  especially  important  when  it  is  nec- 
essary to  place  the  ligature  close  to  an  important  collateral  branch. 

Traumatism,  aside  from  the  reduced  resistance  consequent 
upon  it,  reduces  the  circulation  through  the  injured  tissue  in  pro- 
portion to  it>  intensity,  and  serves  as  a  predisposing  cause  of  in- 
flammation. So  true  is  this,  that  in  many  infections  trauma  is  a 
frequent  and  important  item  of  anamnesis.  Experimentally, 
inflammatory  processes  can  be  produced  with  far  greater  readiness 
when  the  field  has  been  prepared  by  trauma. 

Stagnation  of  the  blood  or  congestion,  whatever  may  be  the 
source  of  it,  especially  passive  congestion,  favored  always  by  de- 
pendent position  of  the  part,  serves  well  as  a  predisposing  factor. 
Tliis  is  seen  on  the  surface  of  the  body  more  often  in  cases  of  ex- 
tensive varicose  veins.  It  is  common  knowledge  how  frequently 
the  legs  and  ankles  of  patients  having  varicose  veins  in  the  legs 
suffer  from  localized  inflammation,  and  how  intractable  such  inflam- 
mation  is  once  it  has  developed;  how,  too,  sufferers  from  hemor- 
rhoids are  repeatedly  harassed  by  inflammatory  and  ulcerative 
complications. 

Vascular  spasm,  when  long  maintained,  and,  far  more  frequently, 
arteriosclerosis  serve  the  same  turn,  inasmuch  as  they  do  not 
permit  a  sufficient  blood-supply  to  pass  through  the  lumina  of  the 
vessels.  Hence,  in  the  old,  inflammation  often  follows  slight  in- 
juries, spreads  to  an  alarming  extent,  and  fails  to  respond  to  treat- 
ment. Senile  gangrene  frequently  follows  slight  injury  and  in- 
fection in  individuals  who  have  arteriosclerosis. 

(2)  Deficiency  in  the  Quality  of  the  Blood  (Hemolytic  Anemia) 
or  of  the  Tissues. — Constitutional  diseases,  when  severe  or  pro- 
longed, not  only  have  the  effect  of  reducing  the  quantity  of  blood, 
luit,  at  the  same  time,  they  much  more  certainly  deprive  it  of 
protecting  qualities  and  of  its  power  to  develop  them  when  the 
demand  is  made.  Under  these  circumstances  not  only  does  the 
present  disease  work  its  own  ravages,  but,  at  the  same  time,  serves 
to  predispose  to  other  perhaps  more  fatal  lesions.  By  producing 
poi-ons  and  turning  them  into  the  blood  constantly,  and  by  altera- 
tion of  the  proportion  of  blood  elements,  together  with  diminution 
of  the  patient's  normal  capacity  to  replenish  these  materials  at 
the  normal  rate,  it  is  easy  to  see  how  an  additional  foe  could  gain  a 
foothold  in  ti.—ue  previously  secure  against  it. 
7 


98  PRINCIPLES   OF   SURGERY 

Tuberculosis  in  pure  culture,  severe  enough,  is  greatly  inten- 
sified when  secondary  infections  gain  admission  to  the  partially 
devitalized  field,  and  must  be  fought  with  a  crippled  blood.  Dia- 
betes mellitus,  gout,  rheumatism,  syphilis,  and  rickets  are  other 
constitutional  diseases  tending  hi  the  same  direction.  Again, 
certain  purely  local  disorders  produce  similar  results;  especially 
worthy  of  mention  are  cardiac  lesions  and  renal  and  hepatic  dis- 
turbances of  such  nature  as  to  produce  anemia. 

Alcohol,  when  used  habitually,  reduces  the  opsonic  power  of 
the  blood,  produces  sclerotic  or  fatty  changes  in  the  viscera,  and 
directly  and  indirectly  alters  the  fortifications  of  the  body  against 
disease.  An  illustration  of  this  is  the  poor  resistance  alcoholics 
manifest  against  pneumococcal  infection  as  compared  with  ab- 
stainers. 

Starvation,  whether  it  is  due  to  improper  food  or  to  insuffi- 
cient food,  produces  anemia,  and  favors  the  development  of  in- 
flammation. This  is  observed  perhaps  more  in  young  children  who 
are  being  fed  abundantly  on  foods  they  cannot  digest,  and,  when 
an  inflammation  of  the  alimentary  mucous  membrane  arises,  their 
vitality  is  so  impoverished  by  a  full-fed  starvation  that  they 
readily  succumb. 

The  same  causes  that  interfere  with  the  supply  of  blood 
to  a  part  are  responsible  for  alteration  of  the  quality  of  the  blood 
retained  in  the  part  for  too  great  a  period.  So  this  condition  may 
arise:  the  blood  is  circulating  so  meagerly  through  the  diseased 
field  that  it  may  not  only  be  overcharged  with  refuse  from  normal 
tissue  metabolism,  but,  at  the  same  time,  if  infection  be  present, 
contain  relatively  large  quantities  of  toxins  and  have  a  low  opsonic 
index,  while  the  opsonic  index  of  the  remaining  blood  is  high  and 
the  relative  amount  of  toxins  low. 

The  following  conditions  have  been,  until  within  recent  years, 
considered  as  exciting  causes  of  inflammation,  and  are  maintained 
as  such  by  a  few  at  the  present  day,  but  the  only  inflammatory 
process  greatly  concerning  the  surgeon  is  that  caused  by  infection. 
These  conditions  are  traumatism,  excessive  heat  or  cold  (burns, 
scalds,  and  chilblain),  chemic  agents,  such  as  escharotics  and 
electric  and  x-ray  effects.  So  far  as  trauma  is  concerned,  it  is 
evident  that  the  non-infected  injury  shows  no  inflammation 
beyond  that  of  the  healing  process.  If  this  is  true,  then  we  can 
see  no  reason  for  not  placing  chemic,  thermal,  and  electric  injuries 
in  the  same  group,  inasmuch  as  the  changes  resulting  from  them, 
while  conforming  to  inflammation  up  to  a  certain  point,  thereafter 
are  entirely  unlike  true  inflammation,  especially  as  concerns  their 
remote  effects.  Hence,  we  prefer  to  class  all  these  injuries  as  pre- 
disposing causes  of  inflammation.  From  a  pathologic  point  of 


INFLAMMATION  99 

view,  and  from  the  manifest  intention  of  the  process,  those  inflam- 
matory processes  produced  by  other  causes  may  not  be  differenti- 
ated  from  bacterial  processes. 

Any  combination  of  the  predisposing  causes  may  be  active  in  a 
given  case;  in  truth,  in  many  cases  of  inflammation  many  factors 
have  served  to  predispose  to  or  favor  the  development  of  bacteria 
which  have  gained  access  to  the  tissues.  All  agencies  predisposing 
to  inflammation  favor  its  continuance  and  spread. 

Exciting  Causes  of  Inflammation. — In  the  light  of  the  above 
facts,  it  is  proper  that,  from  a  surgical  viewpoint,  we  recognize 
Inflammation  as  being  produced  solely  by  bacteria — that  is,  by 
living  causes — in  whatever  light  we  may  accept,  from  a  pathologic 
consideration,  those  changes  wrought  in  the  tissues  in  consequence 
of  the  action  of  trauma,  heat,  and  cold,  chemic  agents,  and  electric 
and  radio-active  energy.  The  one  supreme  reason  for  exclusion 
of  these,  and  acceptance  of  micro-organisms  as  the  cause  of  true 
inflammation,  is  that  the  extent  of  the  process  produced  by  the 
former  is  definitely  and  absolutely  determined  by  the  extent  of 
action  during  their  application — i.  e.,  the  amount  of  the  dose  and 
the  corresponding  reaction  and  no  more.  The  changes  wrought  by 
these  agents  remain  confined  permanently  to  the  field  of  applica- 
tion, and  there  is  no  invasion  of  adjacent  tissue  not  affected  at  the 
beginning,  nor  of  remote  tissues  by  transmission  of  the  cause  to 
them  from  the  primary  site.  Neither  can  the  condition  be  trans- 
ferred from  one  individual  to  another.  So  it  is  clear  that  such 
processes  are  of  but  little  concern  to  the  surgeon  except  in  them- 
selves. A  far  different  thing  is  bacterial  inflammation,  such  as  is 
meant  to  be  prevented  by  all  modern  efforts  at  antisepsis  and 
asepsis,  as  is  meant,  in  a  word,  whenever  the  term  "inflammation" 
is  used  nowadays.  True  inflammation  spreads  from  the  atrium, 
giving  admission  to  the  bacteria  which  cause  it,  and  it  spreads  be- 
cause these  bacteria  are  living  organisms,  and  multiply  and  invade 
the  tissues,  or  are  carried  by  accident,  by  the  lymph  or  by  the 
blood,  to  new  and  uninvaded  fields,  causing  similar  changes  in 
these  new  fields.  The  cause  of  inflammation  is  a  multiplying 
ancnt,  :ind  so,  when  true  inflammation  is  once  established,  it  is 
capable  of  wide  dissemination,  and  death  of  the  patient  may  result 
without  further  contril unions  from  outside  the  body.  'It  is  rare, 
indeed,  that  in  a  given  case  of  infection  the  amount  of  toxins  present 
in  the  bacteria  at  the  time  of  introduction,  or  any  amount  they 
could  ever  produce,  would  have  a  deleterious  action  on  the  tissues 
in  either  local  or  constitutional  manifestation:-:  it  is  the  power  of 
multiplication,  doubling  their  numbers  at  incredibly  short  inter- 
vals, and  a>  often  doubling  their  poison-producing  capacity,  that 
makes  inflammation  the  dreaded  thing  it  is.  The  proces-  here 


100  PRINCIPLES   OF   SURGERY 

mentioned  is  capable  of  transfer  not  only  from  tissue  to  tissue  in  a 
single  body,  but  from  individual  to  individual,  by  instruments, 
hands,  dressings,  and  such  like,  which  have  come  in  contact  with 
one  case  and  without  proper  cleaning  are  allowed  to  be  used  on 
another.  It  has  been  shown  in  the  chapter  on  Surgical  Bacteri- 
ology that  the  immediate  action  on  the  tissues  in  all  cases  of  in- 
fection is  by  the  chemic  poisons  they  produce,  not  the  bacteria 
themselves. 

Extent  of  the  Inflammatory  Process. — Various  inflammatory 
processes  are  very  different  in  intensity  and  extent;  an  infection 
of  one  individual  with  a  certain  strain  of  bacteria  produces  insig- 
nificant lesions,  and  another  is  infected  from  him  and  dies  or 
becomes  seriously  ill.  One  species  of  bacteria  habitually  produces 
mild  inflammatory  changes,  while  another  invariably  produces 
violent  processes.  Certain  bacteria  usually  produce  chronic  in- 
flammation, and  others  as  habitually  produce  acute  inflammation. 
The  extent  of  the  ravages  of  inflammatory  processes  and  the 
nature  of  those  processes — that  is,  whether  acute  or  fulminating 
or  chronic — depends: 

(1)  On  the  resistance  of  the  infected  body,  namely,  the  opsonic 
power  and  the  alexins  as  well  as  the  total  quantity  and  general 
condition  of  the  blood,  and  on  the  condition  of  the  tissues  infected; 
that  is,  the  natural  vitality  and   blood-supply  of  those  tissues, 
and  the  extent  to  which  predisposing  causes  may  have  been  brought 
into  action.     Thus,  a  low  opsonic  index  and  a  reduced  total  quan- 
tity of  blood  gives  poor  general  resistance,  and  in  certain  of  the 
local  predisposing  causes,  as  hi  trauma,  burns,  and  frost-bites, 
when  they  have  reached  the  extent  of  destroying  or  damaging  a 
considerable  amount  of  tissue,  it  is  almost  certain  that  more  or 
less  infection  will  occur,  and  very  certain  that  the  vital  resistance 
will  be  poor  in  combating  that  infection. 

(2)  The  virulence  of  the  germs  causing  an  inflammation,  as  has 
been  shown  already,  may  vary  very  widely  for  a  given  species, 
say  a  strain  of  streptococci,  which,  after  passing  through  a  few 
individuals,  may  become  so  intensified  in  virulence  as  to  scarcely 
resemble  its  ancestry,  and  after  a  time  become  attenuated  again 
by  similar  treatment  with  different  hosts.     These  are  well-known 
laboratory  facts.     Again,  the  habitual  mild  toxic  powers  of  some, 
as  Staphylococcus  epidermidis  albus,  and  the  constant  virulence  of 
others,  as  anthrax  and  the  Bacillus  pestis  (Kitasato's  bacillus), 
shows  how  an  extensive  invasion  of  the  former  might  be  insignifi- 
cant in  comparison  with  a  slight  infection  by  the  latter. 

(3)  The  amount  of  the  initial  dose,  or  the  number  of  bacteria 
constituting  the  infection  at  the  beginning,  influences  markedly  the 
result.     A  few  bacteria  may  be  introduced  into  a  wound  with 


INFLAMMATION  101 

impunity;  a  few  more  may  be  added,  and  result  in  a  slight  in- 
flammatory reaction,  but  when  large  numbers  are  introduced  a  I 
one  time  they  may  so  overwhelm  the  protective  forces  as  to  pro- 
duce violent  results  almost  from  the  outset.  The  initial  infection 
is  not  usually  sufficient  to  produce  grave  symptoms  immediately, 
hut  when  an  encysted  abscess  ruptures  into  a  serous  cavity,  or 
when  a  hollow  viscus  pours  its  contents  through  a  perforation,  the 
general  effect  may  be  so  violent  as  to  produce  death  almost 
l>efore  the  inflammatory  process  has  time  to  get  under  way. 
Hence,  not  only  the  initial  dose,  but  the  rapidity  of  general  intoxi- 
cation, dependent  upon  the  absorptive  capacity  of  the  cavity  into 
which  infection  has  entered,  are  large  factors  in  determining  results. 

(4)  The  rate  of  multiplication  of  bacteria  is  another  potent 
factor  for  variation  of  results  in  infection.  One  group,  of  which 
streptococci  head  the  list,  multiply  so  rapidly  and  are  so  toxic  that 
the  defenses  of  the  body  cannot  be  marshalled  until  after  the 
infection  has  passed  beyond  them — hence,  septicemia  is  frequent 
with  this  infection;  on  the  other  hand,  others  are  so  slow  to  multiply 
that  a  chronic,  though  by  no  means  an  essentially  mild,  inflamma- 
tion is  assured  from  the  beginning;  such  a  one  is  the  tubercle 
hacillus. 

Phenomena  of  Inflammation. — What  the  local  appearance  of 
an  inflamed  tissue  may  be,  whatever  variations,  circumstances,  and 
locality  may  impose,  whatever  diversity  and  intensity  local  and  con- 
stitutional symptoms  may  show,  fundamentally  the  changes  occur- 
ring in  the  inflammatory  process  are  the  same.  If  they  vary  in 
degree,  or  if  they  do  not  always  produce  the  same  pathologic 
result,  it  is  because  of  relative  resistance  and  virulence,  and  not 
owing  to  alteration  of  the  process.  The  following  changes  may  be 
observed  under  the  microscope  in  any  thin  living  membrane  sub- 
ject* <l  to  irritants  capable  of  evoking  inflammatory  reaction. 

The  phenomena  of  inflammation  fall  into  three  subdivisions: 

(1)  The  changes  which  affect  the  blood-vessels  and  the  blood. 

(2)  Destructive  or  degenerative  changes. 

(3)  Reparative  changes. 

(1)  Dilatation  of  the  Blood-vessels. — When  an  irritant  acts  upon 
the  tissues  in  sufficient  intensity  to  produce  inflammation,  the  first 
change  observed  is  dilatation  of  the  small  blood-vessels,  venules, 
arterioles,  and  capillaries.     This  dilatation  is  due  to  paralysis  of 
the  va-ocon>trictor  nerves  and  to  the  direct  action  (paralytic)  of 
the  irritant  on  the  musculature  of  the  vessels;  the  lumina  of  the 
vessels,  therefore,  become  of  larger  caliber,  and  admit  an  increase 
in  the  rate  of  flow  of  blood  through  them  and  an  increase  in  the 
qu.mtity  of  blood.      The  dilatation  of  the  capillarie-  i-  pa—ivr. 

(2)  Hyperemia. — This    increased   quantity    of   blood    flowing 


102  PRINCIPLES   OF   SURGERY 

through  the  dilated  vessels  is  known  as  hyperemia,  or  active  con- 
gestion. It  means  an  increased  flow  of  blood  into,  through,  and 
out  of  the  inflamed  tissue,  and  is  purely  a  physical  phenomenon, 
depending  on  the  diminished  resistance  offered  by  the  dilated 
vessels.  In  case  the  endothelium  of  the  blood-vessels  is  destroyed 
or  damaged  the  increase  in  the  rate  of  flow  is  not  observed.  This  is 
seen  where  croton  oil  is  injected  into  the  tissues  and  in  vessels 
damaged  by  trauma. 

(3)  Congestion. — After  hyperemia  has  continued  for  a  short 
time  the  blood-stream  becomes  slower  and  slower,  the  vessels  be- 
come engorged  with  blood-cells  in  increasing  numbers,  until  they 
are  filled  with  the  slowly  moving  columns  of  red  and  white  cells. 
This  is  sometimes  known  as  passive  congestion.     As  the  rate  of 
flow  becomes  slower,  the  leukocytes  drift  on,  more  probably  are 
drawn  by  their  chemotactic  power  to  the  periphery  of  the  stream, 
and  glide  or  roll  along  the  intima  of  the  vessels  until  they  finally 
stop  in  contact  with  the  intima.     The  red  cells  keep  to  the  middle 
of  the  stream.     In  congestion  the  blood  flows  into  the  vessels 
slightly  faster  than  it  flows  out  and  engorgement  of  the  blood- 
cells  results. 

Oscillation. — At  the  last  of  the  stage  of  congestion  the  columns 
of  blood-cells  move  with  decreasing  rapidity,  until  finally  the  pro- 
pelling effect  of  each  cardiac  impulse  is  seen,  with  a  slight  advance 
of  the  column,  which  recedes  somewhat  during  diastole,  and  a 
vibration  back  and  forth  continues  a  short  time  and  ceases,  the  cells 
failing  to  be  driven  further  by  the  heart-beats.  This  to-and-fro 
movement  is  called  oscillation;  it  is  not  a  step  of  the  process,  but  a 
border-line  between  congestion  and  stasis;  the  end  of  the  former, 
the  beginning  of  the  latter. 

(4)  Stasis. — This  stage  is  not  observed  in  all  the  vessels  in  which 
congestion  has  appeared,  as  in  many  of  the  vessels  the  stage  of 
congestion  is  reached,  remains  for  a  time,  and  is  replaced  by  more 
active  circulation  as  the  infection  subsides  or  the  irritant  is  re- 
moved.    In  stasis  the  blood-cells  lie  packed  in  the  vessels  (capil- 
laries) with  no  evidence  of  motion.     They  have  reached  a  stand- 
still.    The  arrangement  of  the  white  and  red  cells  remains  rela- 
tively the  same,  the  red  in  the  center  of  the  lumen,  the  white  at  the 
periphery. 

(5)  Migration  of  Leukocytes,  Exudation,  and  Diapedesis. — These 
three  processes  do  not  follow  the  preceding  in  the  order  named 
here.     They  begin  during  the  stage  of  congestion  and  continue 
through  the  stage  of  stasis. 

(a)  Migration  of  leukocytes  means  the  passage  of  the  white  cor- 
puscles, usually  the  polymorphonuclear  cells,  from  within  the  ves- 
sels through  the  vessel  walls  into  the  perivascular  spaces,  where 


INFLAMMATION  103 

they  serve  their  purpose  of  destroying  bacteria,  and  are  then  known 
as  phagocytes.  The  point  of  exit  of  leukocytes  through  the  vessel 
walls  is  between  the  endothelial  cells  of  the  intima,  where  they  are 
held  together  by  cement.  The  method  of  passage  of  leukocytes 
through  the  capillary  walls  depends  on  the  capacity  of  these  cells 
to  move  like  amebse;  hence  the  motion  is  called  "ameboid  move- 
ment." The  leukocyte,  lying  against  the  intima,  projects  a  small 
fiim« -r-like  process  of  its  protoplasm  through  the  opening  between 
the  intima  cells ;  this  finger-like  process  is  known  as  a  pseudopodium. 
The  protoplasm  of  the  leukocyte  now  gradually  flows  or  moves  into 
the  distal  extremity  of  the  pseudopodium,  which  lies  outside  the 
vessel;  this  outside  tip  of  the  pseudopodium  therefore,  becomes 
larger  as  the  body  of  the  cell  lying  within  the  vessel  grows  smaller, 
until  nothing  of  it  is  left  within  the  vessel.  Now  the  finger-like 
projection  is  withdrawn  from  the  intracellular  crevice,  and  the 
leukocyte  is  free  to  wander  to  its  destination  in  the  infected 
region. 

."\  I  igration  of  leukocytes  takes  place  continuously  in  the  normal 
Kody,  apparently  as  a  physiologic  process,  and  in  the  healing  pro- 
cess. The  fullest  passage  of  these  cells  through  the  vessel  walls, 
however,  occurs  in  cases  of  infection,  where  they  migrate  in  num- 
bers sufficient  to  invade  and  surround  as  a  wall  the  whole  field  of 
infection. 

(6)  Exudation  is  produced  at  the  same  tune  as  migration  of 
leukocytes;  it  is  more  than  a  filtration  of  blood  fluids  through  the 
vessel  walls.  The  walls  of  the  vessels  become  more  permeable  in 
inflammation,  and  the  endothelial  cells  exert  what  is  termed  by 
certain  authors  a  secretory  function,  pouring  into  the  surrounding 
tissues  substances  which  do  not  ordinarily  come  from  the  blood 
except  under  abnormal  environment  (the  presence  of  toxins,  etc.). 
This  exudate  differs  from  transudates  and  lymph  in  possessing  a 
greater  quantity  of  albumin.  As  the  exudate  is  poured  out,  it 
tills  the  space  \uth  fluid  and  produces  an  edematous  condition. 
It  carries  with  it  the  antiseptic  and  opsonic  properties  of  the 
blood  and  withal  dilutes  the  toxin  present. 

(c)  Diapedesis  signifies  the  passage  of  red  blood-cells  through 
the  vessel  walls,  which,  so  far  as  we  know,  is  purely  accidental  and 
has  no  practical  significance.  The  erythrocytes  are  thought  to 
pass  through  the  openings  made  by  the  leukocytes. 

(>i)  Rhexis  is  another  passive  or  accidental  and  unimportant 
condition.  It  means  the  rupture  of  small  vessels  and  the  escape 
of  their  contents  into  the  tissues. 

Rhexis  and  diapedesis  occur  inconstantly,  and  must  be  ac- 
eepte  1.    MS   stated   above.   MS   accident.-:    the   iinportMiit 
occurring  under  thi.-  division  are  migration  and  exudation. 


104  PRINCIPLES   OF   SURGERY 

Destruction  of  Tissue  in  the  Inflammatory  Process. — If  we  accept 
the  term  inflammation  as  meaning  those  local  processes  or  reactions 
called  forth  by  infection,  and  exclude  the  pathologically  identical 
processes  called  forth  by  trauma,  thermal,  chemic,  and  electric 
agencies  (the  healing  process),  then  there  are  certain  changes  of  a 
destructive  nature  going  on  continuously  in  inflamed  tissue,  more 
marked  and  intense  in  proportion  to  the  virulence  and  abundance  of 
the  causative  bacteria.  These  degenerative  changes  are  due  to 
the  poisons  liberated  by  the  bacteria  acting  on  the  tissues.  If  the 
circulation  is  sufficiently  interfered  with,  the  diminution  of  the 
blood-supply  or  its  entire  interruption  adds  further  to  the  causation 
of  necrosis.  The  tissues  that  die  are  partially  or  completely  lique- 
fied by  the  leukocytes  and  their  ferments  and  by  the  digestive 
powers  of  the  bacteria.  If  the  amount  of  tissue  destroyed  is  not 
too  great  in  quantity,  clinical  evidences  of  such  destruction  are 
wanting,  and  all  the  dead  tissue  is  removed  from  the  field  by  living 
leukocytes.  If  the  amount  of  destroyed  tissue  is  too  great  to  be 
handled  in  this  way,  it  appears  in  observable  quantities,  in  the  form 
of  necrotic  masses  or  pus,  and  can  be  removed  only  by  artificial  or 
accidental  means. 

Regeneration  or  repair  of  the  damage  done  by  the  irritants 
acting  on  the  tissues  is  begun  as  soon  as  the  irritants  are  removed 
or  reduced  in  quantity,  and  in  those  cases  where  this  end  is  not 
early  accomplished  the  reparative  process  is  begun  at  the  outer 
limits  of  the  inflamed  area.  This  reparative  process  is  in  no  way 
different  from  that  described  under  the  Healing  Process,  and 
accomplishes  the  same  end  by  replacing  destroyed  tissue  with 
connective  tissue  or  bone,  as  the  case  may  be.  The  regeneration  of 
tissue  here  may  go  so  far  as  to  establish  new-formed  blood-vessels 
in  a  tissue  normally  devoid  of  them.  Regeneration  of  parenchy- 
matous  tissue  may  also  sometimes  result  from  chronic  inflamma- 
tory processes. 

Inflammation  of  Non-vascular  Tissue. — In  tissue  having  no 
direct  blood-supply,  such  as  the  cornea  and  cartilage,  the  inflam- 
matory process  develops  in  response  to  the  application  of  the 
causes  to  those  tissues.  The  vascular  changes  appear  in  the  closest 
capillaries,  and  the  exudate  and  leukocytes  are  carried  to  the  field 
of  action  through  the  lymph-channels  and  spaces  which  normally 
convey  nourishment  to  the  parts.  So  that,  while  no  vessels  are 
present  in  these  tissues,  the  essential  factors  contributed  by  the 
blood  are  soon  brought  into  action,  and  the  degenerated  areas  are 
repaired  in  the  same  manner,  if  more  slowly  and  somewhat  more 
uncertainly  so  far  as  may  concern  function,  as  where  a  direct  blood- 
supply  exists.  The  function  of  non-vascular  tissues  after  inflam- 
mation is  dependent  on  the  same  conditions  as  that  of  vascular 


INFLAMMATION  105 

tissue,  namely,  the  extent  of  replacement  of  normal  tissue  by  new 
tissue  formation. 

The  Spread  of  Inflammation. — Those  so-called  inflammatory 
processes  which  are  not  produced  by  living  agents  in  the  tissues 
cannot  extend  from  the  place  of  application  of  the  cause.  A 
wound  is  made,  calls  forth  a  certain  reparative  inflammation 
(healing  process)  which  concerns  only  the  tissues  damaged,  and 
not  in  the  least  concerns  remote  or  even  adjacent  structures. 
The  same  is  true  of  the  hypodermic  injection  of  irritant  chemicals 
and  of  burns.  The  process  evoked  by  pathogenic  bacteria,  how- 
ever, is  a  constant  menace,  not  only  to  adjacent  structures,  but  to 
various  remote  structures,  even  to  the  whole  body,  because  of  the 
fact  that  the  cause  may  be  transferred  to  other  tissues,  gain  a  foot- 
ing, and  produce  a  similar  process  there. 

An  inflammation  may  spread  by  four  distinct  routes — they  are, 
by  continuity,  by  contiguity,  through  the  blood,  through  the 
lymph.  It  would  be  more  accurate  to  state  that  bacteria  causing 
a  given  inflammation  may  spread  from  their  primary  focus  in  either 
or  all  these  ways,  and  wherever  they  find  lodgment  may  establish 
a  new  process.  It  is  not  to  be  forgotten  that  the  inflammation 
per  se  is  a  corrective  effort. 

Spreading  by  Continuity. — An  infection,  or  inflammation,  is 
said  to  spread  by  continuity  when  the  process  spreads  hi  a  single 
tissue  or  structure  without  involving  other  structures  or  tissues, 
and  when  it  spreads  directly  and  uninterruptedly  in  a  single  organ 
or  part.  For  example,  if  an  inflammation  begins  in  the  skin  and 
spreads  continuously  from  the  atrium,  but  does  not  involve  other 
ti— ues,  it  spreads  by  continuity.  If  the  process  spreads  from  the 
skin  at  the  body  apertures,  and  directly  extends  to  the  mucous 
membrane,  it  spreads  by  continuity;  if  in  a  bone,  a  joint,  or  other 
body  cavity,  the  method  is  the  same  so  long,  and  only  so  long,  as  it 
keeps  within  the  bounds  of  that  particular  anatomic  structure  and 
spreads  without  interruption. 

Spreading  by  Contiguity. — When  an  inflammatory  process 
originates  in  one  structure  and  spreads  from  it  into  an  adjacent 
structure  across  a  real  or  virtual  chasm  it  spreads  by  contiguity. 
For  example,  the  spread  of  inflammation  from  parietal  to  opposed 
vi-r<-ral  pleura  illustrates  the  same  method,  from  one  coil  of  intes- 
tine to  another  in  contact  with  it,  or  from  the  tongue  to  the  roof  of 
the  mouth. 

Spreading  by  the  Blood. — If  a  few  bacteria  be  contained  in  an 
emholus  that  escapes  from  the  primary  focus,  and  when  lodged 
produce  a  similar  process,  the  spread  is  through  the  blood.  Or,  as 
happens  when  the  blood  becomes  generally  contaminated  with 
bacteria  and  various  parts  of  the  body  become  affected,  the  bacteria 


106  PRINCIPLES   OF   SURGERY 

may  lodge  upon  the  intima  of  small  vessels,  especially  where  the 
blood-current  is  slow.  This  is  seen  in  all  metastatic  infections,  and 
is  especially  noticeable  in  metastatic  erysipelas,  as  the  inflamma- 
tion is  superficial  and  visible. 

Spreading  by  the  Lymphatics. — Just  as  the  bacteria  may  be  dis- 
tributed indiscriminately  by  the  blood,  they  are  carried  along  some- 
what more  definite  channels  by  the  lymph- current,  when  they  have 
gained  an  entrance  into  it,  as  they  always  do.  Many  times  no 
clinical  evidence  exists,  but  it  is  very  doubtful  if  ever  an  infection 
is  present  in  which  the  lymph  escapes.  The  infection,  if  intense, 
may  produce  a  general  Infection  of  the  lymph-spaces,  channels, 
and  nodes  of  the  region  affected.  More  often  the  former  two  escape 
and  the  infected  lymph  is  carried  to  the  nearest  lymph-node  down- 
stream, which  filters  out  the  bacteria,  and  disposes  of  them  if 
possible  by  means  of  its  contained  phagocytes,  or,  if  this  fails, 
becomes  inflamed.  If  bacteria  escape  this  node  they  go  to  the 
next,  and  so  on,  until  the  lymph  is  poured  into  the  blood.  There- 
fore it  is  possible  for  a  septicemia  to  occur  through  lymphatic 
infection.  Up-stream  lymph-node  involvement  is  said  to  occur, 
though  somewhat  rarely.  It  is  explained  on  the  ground  that  the 
normal  outlet  of  lymph  from  the  infected  region  has  become 
blocked,  thus  necessitating  a  retrograde  current,  which  forces 
bacteria  into  nodes  that  would  escape  if  the  channels  had  remained 
patent.  Thevfact  is  of  practical  value,  and  should  always  be  borne 
in  mind  when  searching  for  lymphatic  metastases. 

To  illustrate  the  methods  of  spread  of  inflammation,  let  us 
suppose  the  tongue  has  become  infected  and  inflamed.  First,  the 
infection  extends  throughout  the  tongue  by  continuity.  Second,- 
that  the  mucous  membrane  of  the  palate  becomes  infected  from 
contact,  i.  e.,  by  contiguity.  Third,  the  submaxillary  and,  later, 
the  upper  cervical  nodes  become  infected  from  bacteria  carried 
through  the  lymphatics.  Fourth,  a  suppurative  focus  is  formed 
and  a  blood-clot  blocking  the  mouth  of  a  vessel,  destroyed  by  the 
degenerative  process,  is  disintegrated,  and  allows  fragments  of  the 
infected  clot  to  escape  through  a  vein;  these  lodge  somewhere,  say 
in  the  liver,  and  produce  an  inflammation  and  perhaps  one  or 
more  abscesses,  or,  if  pus  enters  with  the  clot,  they  produce  a 
pyemia. 

Terminations  of  the  Inflammatory  Process. — The  outcome 
of  inflammatory  processes  is  very  variable,  ranging  from  no 
perceptible  final  abnormality  to  the  most  extreme  permanent 
impairment  or  loss  of  function  and  more  or  less  complete  destruc- 
tion of  tissue,  and  even  the  death  of  the  patient,  which  results 
either  from  the  general  effect  of  the  bacterial  poisons  or  from  im- 
pairment of  function  of  vital  organs.  The  termination  of  an 


INFLAMMATION  107 

inflammation  may  be  expressed  as  the  resultant  of  the  combating 
forces,  the  tissues  against  the  bacteria.  According  to  the  final 
balance  of  these  forces  the  terminations  are: 

(1)  Delitescence. 

(2)  Resolution. 

(3)  Suppuration. 

(4)  Gangrene. 

(5)  New  Tissue  formation. 

(1)  Delitescence. — When  an  inflammation  is  initiated,  but  by 
causes  incapable  of  maintaining  or  firmly  establishing  a  stand,  and 
the  usual  stages  are  not  developed,  the  cause  being  removed  or 
ovm-ome,  whether  by  natural  or  artificial  forces,  it  is  said  to 
terminate  by  delitescence.     Delitescence  is  the  cutting  short  of  an 
inflammatory  process  or  an  abortive  inflammation.     Hyperemia, 
and  even  congestion,  may  develop,  but  the  condition  does  not  con- 
tinue long,  and  subsides  in  a  few  hours  to  a  day  and  a  half  subse- 
quent to  beginning.     This  termination  is  the  result  of  a  mild 
infection  or  of  a  marked  resistance  on  the  part  of  the  tissues,  such 
as  partial  immunity  or  of  active  therapeutic  measures.     In  such 
cases  the  infection  is  early,  easily,  and  completely  overcome  by  the 
protective  agencies  of  the  body. 

(2)  Resolution. — An  inflammation  may  run  through  all  the 
stages — dilatation    of    vessels,     hyperemia,     congestion,    stasis, 
diapedesis,  and  exudation — and  yet  the  tissues  not  be  much  the 
worse  after  it  is  finished.    Resolution  has  a  positive  and  a  negative 
significance.     It  presupposes  a  well-developed  inflammation.     Its 
positive  significance  is  that  there  has  been  slight  tissue  destruction, 
slight  enough  to  produce  no  gross  evidence  of  it;  that  the  tissues 
were  able  to  overcome  the  infection  and  return  to  normal  without 
perceptible  portions  of  them  being  destroyed  by  the  bacteria. 
Resolution  signifies  the  most  complete  possible  victory  for  the 
ti— IK -.     NYgatively,  resolution  is  that  termination  of  an  inflam- 
matory process  in  which  neither  pus  nor  death  of  macroscopic 
portions  of  tissue  occurs,  and,  therefore,  is  the  ideal  termination, 
MI i less,    perchance,    delitescence    could    have    occurred    or    been 
imhiccd,  which  is  rare.     It  is  the  result  of  a  fight  between  bacteria 
and  the  body  cells  and  fluids,  in  which,  however  fierce  the  battle 
may  have  raged,  and  however  grave  the  general  condition  of  the 
pat  lent .  the  bacteria  are  overcome  by  the  protective  agents  and  the 
least  possible  amount  of  repair  is  necessary. 

(3)  Suppuration. — This  termination  occurs  in  every  instance 
where  pus  is  found.     The  amount  of  pus  may  vary  relatively  to 
the  total  value  of  inflamed  tissue,  in  one  in-tance  the  whole  of  it 
becoming  a  suppurative  mass,  in  another  only  portions  of  it,  per- 
hap>  relatively  very  small  portions  becoming  purulent.     The  pus 


108  PRINCIPLES   OF   SURGERY 

may  be  so  confined  as  to  accumulate  and  give  an  exact  measure  of 
its  quantity,  while  in  another  instance  it  may  not  be  confined,  and 
its  escape  admit  of  no  adequate  judgment  of  the  quantity.  Ter- 
mination of  inflammation  by  pus  production  is  evidence  that  the 
bacteria  have  gained  the  victory  to  that  extent,  and  the  amount  of 
pus  is  essentially  an  index  of  the  extent  of  sacrifice  of  tissue.  The 
leukocytes  resisting  the  bacteria  are  poisoned  by  them  until  they, 
and  somewhat  of  the  tissues  concerned  in.  the  inflammation,  die, 
and  become  pus-cells.  Surrounding  the  pus-forming  area  the  leuko- 
cytes marshal  their  forces  more  perfectly  and  arrest  further  invasion, 
but  the  extent  of  pus  formation  is  the  measure  of  the  victory  the 
bacteria  have  won,  though  they  may  later  be  vanquished.  It  is 
manifest,  therefore,  that  a  wide  area  of  suppuration,  or  prolonged 
formation  of  large  quantities  of  pus,  cannot  fail  to  be  a  serious 
draft  on  the  vital  resources  of  the  body,  to  say  nothing  of 
depreciation  of  their  resistive  capacity  by  continued  absorption  of 
toxins.  When  the  process  is  finished,  and  pus  has  ceased  to  form, 
and  when  the  inflammation  surrounding  the  pus  zone,  not  intense 
enough  to  produce  pus,  has  resolved,  the  breaches  made  in  the 
tissues  are  repaired  by  formation  of  cicatricial  tissue.  Recovery 
occurs,  but  the  tissues  are  crippled. 

(4)  Gangrene. — When  an  inflammatory  process  is  produced  by 
toxins  so  virulent  and  so  abundant  as  to  destroy  the  vitality  of  a 
portion  of  the  tissues  affected,  gangrene,  or  death  of  tissue,  is 
established.  This  is  favored  by  a  predisposing  trauma,  which  re- 
duces the  vitality  of  the  cells  and  interferes  somewhat  with  the 
vascular  and  lymphatic  structures  of  the  part;  the  recuperative 
powers  are,  therefore,  crippled  and  poorly  equipped  to  deal  with 
their  double  task  of  controlling  an  Infection  and  repairing  traumatic 
injury.  Of  course,  if  the  trauma  be  sufficient  of  itself  to  devitalize 
the  tissue  directly,  or  indirectly  through  destruction  of  afferent  or 
efferent  blood-vessels,  no  inflammatory  reaction  can  occur.  The 
swelling  of  inflammation,  if  it  be  severe,  causes  a  diminution  of  the 
circulating  blood  and  lymph,  and  permits  undue  concentration  of 
bacterial  poisons  in  the  region  concerned,  and  so  favors  termina- 
tion by  gangrene.  Likewise,  thrombosis,  appearing  in  a  con- 
siderable percentage  of  the  small  vessels,  tends  to  produce  the  same 
result  in  the  same  manner.  In  a  word,  an  inflammatory  process 
may  result  in  death  of  masses  of  tissue,  when  the  infection  is  so 
virulent  and  so  abundant,  whether  aided  or  unaided  by  other 
factors,  as  to  overwhelm  the  tissues  and  kill  them  without  admitting 
any  adequate  reaction  on  their  part.  The  most  frequent  example 
of  such  processes  is  found  in  acute  fulminating  appendicitis. 

In  strict  accuracy,  it  is  better  to  consider  gangrene  as  an  acci- 
dent happening  during  the  course  of,  and  because  of,  the  inflam- 


INFLAMMATION  109 

matory  process  rather  than  as  a  termination.  Yet,  if  we  are 
forced  to  admit  that  destructive  changes  habitually  occur  in  inflam- 
mation,  even  those  terminating  by  resolution,  it  becomes  mani- 
festly only  a  question  of  degree  when  we  classify  gangrene  in  this 
eategory. 

(5)  New  Tissue  Formation. — As  the  destructive  effects  of  in- 
flammation occur,  so  constructive  work  must  be  done  to  repair 
such  damage.  This  is  true  to  some  extent  in  acute  inflammation. 
Th<-  longer  the  process  is  prolonged,  the  more  likely  this  termina- 
tion and  the  greater  the  quantity  of  new  (fibrous  or  cicatricial) 
tis>ue  formed.  The  immediate  result  of  an  infection  is  to  produce 
certain  vascular  and  perivascular  changes.  The  leukocytes  de- 
posited in  and  around  the  infected  zone  are  aided,  if  the  inflamma- 
tion  \K  subacute  or  chronic,  by  the  formation  of  cicatricial  tissue 
which  serves  to  help  the  leukocytes  in  their  effort  to  limit  the  spread 
of  infection  by  building  a  permanent  living  wall  around  them. 
This  artificial  tissue  may  completely  encyst  the  infection  and  limit 
it  to  that  particular  spot  for  indefinite  periods,  even  for  many  years. 
In  t  his  instance  the  bacteria  remain  encysted  and  are  so  long  harm- 
less, but  when  by  accident  they  become  liberated  from  their  en- 
ca>rment  they  rekindle  their  activity,  possibly  with  rapid  and 
fatal  effect.  In  certain  cases  the  new-formed  fibrous  tissue  be- 
comes calcified  in  part  or  throughout  and  effects  permanent  cure 
of  the  infection.  This  is  seen  in  old  inflamed  lymph-nodes.  The 
new-formed  fibrous  tissue  may  be  no  detriment  to  the  organism, 
or,  by  its  interference  with  important  functions,  produce  the  most 
direful  results.  So,  where  new  tissue  results  from  peritonitis,  adhe- 
>ion<  may  impede  peristalsis  or  cause  intestinal  obstruction;  in  the 
joints  ankylosis,  m  the  urinary  bladder  and  gall-bladder  contrac- 
tion occurs,  and  the  capacity  of  the  organs  is  diminished  until  they 
will  contain  only  a  few  drops  of  urine  or  bile.  When  cicatricial 
ti— ue  forms  from  a  diffuse  inflammation  of  an  organ  the  resultant 
contraction  causes  atrophy  and  diappearance  of  the  stroma. 

Long  before  any  of  the  above  terminations  have  had  time  to 
follow  the  infection  which  evoked  the  inflammatory  process  the 
patient  may  die  of  general  intoxication,  or,  because  of  the  very 
fact  that  t  he  response  to  infection  has  been  so  extensive  and  intense 
its  to  su>peml  a  vital  function,  death  ensues  while  the  inflammatory 
react  \( n\  is  at  its  height.  So  in  inflammation  of  the  vital  nerve-cen- 
'«  r-.  in  inflammation  of  the  lungs,  in  inflammation  of  the  kidneys, 
while  the  general  condition  may  remain  unimpaired  directly 
l»y  the  infection,  yet  these  organs,  necessary  to  life,  have  their 
function  -impended  or  so  impaired  as  to  render  that  function  in- 
adequate. 

Signs  and  Symptoms  of  Inflammation. — Signs  and  symptoms 


110  PRINCIPLES   OF   SURGERY 

of  inflammation  are  divided  into  local  and  constitutional.  The 
former  are  discussed  first,  being  in  a  general  way  the  more  impor- 
tant of  the  two,  inasmuch  as  they  concern  the  process  directly, 
although  the  constitutional  symptoms  offer  a  better  index  to  the 
extent  of  the  general  impression,  and  may,  when  the  site  involved 
is  deeply  enough  placed  to  render  it  inaccessible  to  observation  of 
local  signs,  be  the  chief  evidence  for  concluding  that  an  inflam- 
matory process  is  in  action. 

LOCAL  SIGNS  AND  SYMPTOMS. — The  local  signs  and  symptoms 
of  inflammation  have  come  down  to  us  from  the  days  of  the  old 
Roman  physicians  practically  without  modification.  They  are 
five  in  number,  heat,  discoloration  (redness),  pain,  swelling,  and 
impaired  function  (calor,  rubor,  dolor,  tumor,  functio  Icesa). 

(1)  Heat. — In  every  inflamed  region  the  temperature  of  the 
part  is  elevated  somewhat  above  the  corresponding  part  on  the 
opposite  side  of  the  body,  that  is,  is  higher  than  it  would  be  if  the 
part  were  not  inflamed.  This  statement  is  true  regardless  of  the 
general  body  temperature,  which  may  be  normal,  subnormal,  or 
above  normal.  The  abnormal  temperature  of  the  body,  whether 
above  or  below  normal,  may  be  due  to  the  infection  causing  the 
inflammatory  reaction  or  to  other  causes;  the  relative  temperature 
of  the  inflamed  tissue  maintains  itself  at  a  little  higher  point. 

The  increase  of  temperature  may  be  recognized  by  the  use  of  a 
surface  thermometer,  the  part  involved  always  being  compared 
with  its  corresponding  part  on  the  opposite  side  of  the  body,  hand 
with  hand,  right  side  of  chest  with  left  side  of  chest,  thigh  with 
thigh.  If  for  any  reason  such  comparison  cannot  be  made,  then 
the  temperature  over  the  inflamed  region  must  be  compared 
with  the  surrounding  healthy  tissues.  The  difference  in  tempera- 
ture between  inflamed  and  healthy  tissues,  if  there  be  a  fairly 
extended  process,  is  perceptible  to  the  hands  applied  upon  them. 
In  those  cases  in  which  the  inflammatory  process  does  not  involve 
a  surface  the  difference  between  healthy  and  diseased  sides  can 
still  be  detected,  less  marked,  by  the  surface  thermometer,  if  an 
extensive  active  inflammation  be  present. 

(a)  The  cause  of  this  local  increase  of  heat  is  due  chiefly  to  the 
increased  amount  of  blood  to  the  inflamed  tissue,  the  blood  in  the 
internal  organs  being  of  higher  temperature  than  at  the  surface, 
where  its  heat  is  constantly  lost.  The  greater  the  quantity  of 
blood  brought  into  an  inflammatory  zone  the  higher  the  local 
temperature  will  rise,  but  it  never  exceeds  the  temperature  of  the 
internal  blood  at  the  time  of  observation. 

(6)  The  increased  chemic  activity  of  inflammation  was  for- 
merly though  to  be  one  of  the  chief  causes  of  the  local  increase  of 
temperature,  but,  as  the  limit  seems  to  be  the  temperature  of  the 


INFLAMMATION  111 

internal  blood,  no  great  increase  can  be  attributed  to  this  source. 
1 1  ( loubtless  contributes  a  small  part. 

(c)  Diminished  Radiation. — When  inflammation  involves  a 
cutaneous  surface,  a  part  of  the  increase  in  local  temperature  may 
be  attributed  to  diminished  radiation,  due  to  disturbance  of  the 
skin  glands  and  a  consequent  reduction  in  the  quantity  of  moisture 
they  liberate. 

(2)  Discoloration  or  Redness. — In  all  inflammatory  changes  the 
tissues  affected  become  discolored  by  the  increased  quantity  of 
blood  present.     It  is  usually  spoken  of  as  redness,  and  usually  the 
color  is  red,  but  it  is  manifest  that  it  may  vary  all  the  way  from 
the  brightest  red  of  well-oxygenated  blood  to  the  darkest  blue  of 
venous  blood.     And  this  is  an  important  index  to  the  condition 
of  the  circulation  of  the  part.     If  the  color  be  cyanotic  or  purple,  it 
signifies  a  much  slower  circulation,  and  indicates  that  sufficient 
blood  is  not  passing  through  the  vessels  to  take  care  of  the  infec- 
tion.    Just  so  in  trauma  without  infection,  the  color  of  the  tissues 
shows  to  what  extent  vascular  damage  has  been  wrought.     Where 
such  a  condition  obtains  it  is  a  sign  of  danger,  and  every  effort 
should  be  enacted  to  increase  the  activity  of  the  circulation.     In 
trauma  it  presages  gangrene  or  slough,  in  inflammation  it  means 
that  tissue  destruction  is  impending,  whether  gangrene  or  abscess. 

Where  the  swelling  is  intense  there  may  appear  yellowish-pink 
areas  over  the  surface,  showing  that  the  blood  has  been  pressed 
out  of  the  small  vessels  more  or  less  completely  by  the  swelling. 
This  condition  endangers  the  vitality  of  the  tissues  by  depriving 
them  of  blood.  Fortunately,  these  yellow  spots  are  usually  small. 

Pressure  on  inflamed  tissue  forces  the  blood  out  of  the  vessels 
and  renders  the  surface  pale.  Removal  of  that  pressure  allows  a 
return  of  the  color;  the  rate  of  the  return  is  an  index  to  the  condi- 
tion of  t  he  circulation.  A  rapid  resumption  of  color  showing  active, 
a  -li  >w  resumption  showing  poor,  circulation.  In  tissues  where  the 
proccs^  has  completely  blocked  the  vessels,  and  thrombosis  in  the 
capillaries  has  occurred,  pressure  has  little  effect  on  the  color. 

(3)  Pain. — As  in  many  other  diseased  conditions,  so  in  inflam- 
mation,  pain  is  one  of  the  most  prominent,  most  deceptive,  and 
11  Ki-t    important  symptoms.     In  the  majority  of  inflammatory 
c<  mi  lit  i<>n<  it  i-  this  symptom  that  causes  the  patient  to  seek  the 
physician'-  aid. 

Pain  i>  ilue  in  inflammation  to  the  swelling  and  the  toxins,  and 
i>  produced  by  U/)  stretching  of  the  nerve-fibers;  (6)  pressure  on  the 
nerve-  or  their  endhm-:  e)  irritation  of  the  nerve-endings  by  bac- 
terial poi-on-.  The  nerve  ti»ue  itself  may  Kecome  inflamed  and 
contribute  to  the  pain  already  pre-ent.  Init  it  doe-  so  in  accordance 
with  the  three  item-  alxjve. 


112  PRINCIPLES   OF   SURGERY 

The  study  of  pain,  so  vast  in  detail,  so  unsatisfactory  in  practical 
application,  can  be  entered  into  here  only  in  an  elementary  fashion. 
These  fundamental  points  in  connection  with  it  will  be  laid  down  as 
a  guide,  and,  it  is  hoped,  as  a  stimulus  to  investigate  more  elabor- 
ately the  more  extensive  works  devoted  exclusively  to  the  subject. 

Types  of  Inflammatory  Pain. — The  presence  of  an  inflammation 
in  various  tissues  and  organs  gives  rise  to  very  different  types  of 
pain.  When  a  skin  surface,  or  a  mucous  surface  at  or  near  the 
apertures  of  the  body,  such  as  nose,  mouth,  eye,  vagina,  urethra, 
and  rectum,  is  inflamed  the  pain  is  itching  or  burning;  it  is  some- 
times scalding  or  tickling  on  the  mucous  surfaces,  especially  the 
latter  in  the  upper  air-passages  and  the  former  in  the  urethra. 
If  inflammation  attacks  a  serous  surface,  particularly  the  pleura 
or  peritoneum,  the  pain  is  described  as  sharp,  keen,  cutting,  stab- 
bing, or  lancinating;  when  inflammation  of  these  surfaces  is  chronic, 
it  is  less  likely  to  be  sharp,  except  as  acute  exacerbations  occur, 
and  is  usually  described  as  dull,  dragging,  or  aching.  The  remain- 
ing serous  surfaces,  namely,  the  synovial,  do  not  show  the  intense 
keen  pain  so  frequently,  although  it  may  be  intense;  it  is  more  like 
the  pains  produced  by  inflammation  of  bone.  Acute  peritonitis 
and  acute  pleuritis  offer  the  best  illustration  of  this  type  of  pain. 
In  inflammation  of  the  viscera,  when  their  serous  surfaces  are  not 
involved,  the  pain  is  described  as  dull,  heavy,  or  aching  in  charac- 
ter. So  the  pain  from  a  hepatitis  or  a  nephritis  or  a  pulmonitis 
is  of  this  type,  if,  indeed,  pain  be  present  at  all.  An  exception  to 
this  rule  is  found  in  acute  pancreatitis,  where  the  most  violent 
cutting  pains  are  felt,  as  in  perforative  peritonitis.  When  a  viscus 
is  inflamed  primarily,  and  the  serous  covering  becomes  later  in- 
volved by  extension  of  the  infection,  the  symptoms  show  the  char- 
acteristic sharp  pain  of  the  latter.  Example,  a  central  pneumonia, 
later  extending  to  the  lung  surface  and  involving  the  pleura.  The 
pain  produced  in  inflammation  of  bone,  cartilage,  and  periosteum  is 
of  a  dull  aching  or  boring,  gnawing  nature  and  is  usually  worse  at 
night  (or,  better,  at  the  regular  period  of  sleep).  This  is  true 
whether  the  pain  be  due  to  acute  or  chronic  inflammation,  although 
the  pain  is  necessarily  more  intense  in  the  acute,  other  things  being 
equal.  Still  an  exception  is  found  in  syphilitic  pains  in  the  bones, 
essentially  chronic,  and  almost  invariably  worse  at  night. 

Throbbing  pain  is  produced  in  inflammatory  processes  confined 
in  more  or  less  inelastic  cavities  or  spaces.  The  exudate  fills  up  the 
spare  room,  and  as  each  systole  of  the  heart  drives  more  blood  into 
the  vessels  it  increases  the  pressure  and  exacerbates  the  pain. 
So  each  throb  represents  a  heart-beat.  This  type  of  pain  is 
observed  in  ofchitis,  certain  subperiosteal  inflammations,  as  whit- 
low, and  in  inflammation  of  the  tooth-pulp. 


INFLAMMATION  1 13 

Colicky  or  cramping,  bearing  down,  or  straining  pains  are 
found  when  the  inflammation  involves  the  lining  of  a  hollow  viscus. 
So  in  inflammation  of  the  mucous  membrane  of  the  stomach,  not 
only  may  the  burning  pain  be  present,  but,  at  the  same  time,  what 
is  described  as  "stomach  cramps."  In  inflammation  of  the  mucous 
m< •lubrane  of  the  intestine  there  may  or  may  not  be  a  burning  sen- 
sation: in  addition,  a  distinct  griping  or  colic  may  be  felt.  In 
inf Ian  11  nation  of  the  caudad  extremity  of  the  gut  the  griping  is 
especially  felt,  and  passes  under  the  name  of  tenesmus,  commonly 
spoken  of  as  "straining,"  and  is  accompanied  with  an  unsatisfied 
i  It -ire  to  empty  the  irritant  from  the  bowel.  In  inflammation  of 
the  bladder  and  the  deep  urethra  the  "burning  like  fire"  is  ac- 
companied by  the  straining  to  empty  the  bladder;  the  straining  to 
dribble  out  a  few  unsatisfactory  drops  of  urine  is  called  strangury, 
ami  is  of  the  same  cramping  nature  as  the  tenesmus  in  rectal  and 
-iirmoidal  inflammation. 

Variations  in  the  intensity  of  pain  must  be  borne  in  mind,  and 
the  fact  must  never  be  forgotten  that  this  variation  may  render  our 
recognition  of  the  true  status  valueless.  One  individual  raves 
hysterically  over  an  insignificant  inflammatory  process,  and  an- 
other tolerates  with  stoical  silence  the  pain  of  a  violent,  extensive, 
and  deadly  inflammation.  So  the  extent  of  complaint  of  pain  must 
not  be  accepted  solely  as  the  measure  of  the  pain  and  of  the  process 
producing  it.  The  physician  must  use  his  utmost  skill  to  read  the 
degree  of  pain  written  on  the  fades,  as  he  would  read  his  ther- 
mometer; even  now  failure  to  appreciate  the  extent  of  the  lesion 
may  occur,  for  not  only  are  the  patients  and  pain  variable,  but 
certain  extensive  inflammatory  processes  are  almost  devoid  of 
pain  in  regions  where  it  is  expected  to  be  found.  So  that  pain 
must  he  considered  as  but  one  of  a  group  of  correlated  indices  to  the 
condition  present. 

Referred  Pain. — The  pain  produced  by  inflammation  may  be 
felt  at  the  site  of  the  lesion,  or  it  may  be  felt  at  some  point  more  or 
less  remote  from  the  inflamed  part.  This  latter  is  spoken  of  as 
referred,  or  reflected,  pain.  It  is  susceptible  of  explanation  on 
anatomic  grounds  in  certain  instances;  in  others,  on  no  hypothesis 
within  1  he  scope  of  our  present  knowledge.  This  reference  of  pain, 
found  in  other  pathologic  conditions  besides  inflammation,  is  sure 
to  mislead  the  patient,  and,  unless  the  physician  is  constantly 
wary,  he  will  fall  victim  to  the  same  deception.  Every  pain  of 
marked  inten-it\  or  prolonged  duration  should  be  investigated  for 
a  cause,  and  no  guess  work  is  allowable  until  exhaustion  of  our 
diagnostic  method-  i-  made. 

Referred  pain  i-  usually  felt  at  some  point  in  the  distribution  of 
a  nerve-supplying  tissue  other  than  the  part  inflamed  (this  is 


114  PRINCIPLES   OF   SURGERY 

probably  due  to  stimuli  short-circuiting  from  one  nerve-fiber  to 
others  adjacent  to  it),  or  it  may  be  referred  to  the  distribution  of 
another  nerve  whose  center  is  closely  associated  with  that  of  the 
nerve  supplying  the  site  of  disease.  Yet  many  times  do  we  find 
referred  pains  affecting  points  remote  from  each  other,  not  only 
from  a  physical  standpoint,  but  remote  in  the  sense  that  they  have 
no  peripheral  or  central  nerve  relationships  so  far  as  can  be  demon- 
strated. The  rule  is,  that  referred  pains  follow  definite  routes; 
however,  this  cannot  be  accepted  as  absolute.  They  may  or  may 
not  be  referred,  and  only  a  knowledge  of  the  usual  direction  of 
reference  can  be  entered  into  here. 

Under  the  general  subject  of  pain  may  be  mentioned  tender- 
ness, which  in  certain  inflammatory  processes  is  of  equal  diagnostic 
value  with  pain;  it  enhances  the  value  of  pain  as  a  diagnostic 
symptom.  Every  inflammatory  process  if  acute,  and  usually  if 
chronic,  is  tender;  there  are  many  painful  conditions,  non-inflam- 
matory, which  are  not  tender,  but,  on  the  other  hand,  are  more  or 
less  relieved  by  pressure;  therefore  the  observation  of  this  tender- 
ness becomes  of  the  utmost  value,  especially  in  those  inflammations 
which  are  situated  so  deep  in  the  tissues  as  to  show  no  surface  signs. 
Often  after  the  acute  inflammation  has  subsided,  and  practically 
all  of  its  immediate  symptoms  have  vanished,  tenderness  remains 
as  the  sole  index  to  the  true  nature  of  a  past  attack.  For  ex- 
ample, consider  the  tenderness  remaining  indefinitely  after  an 
attack  of  acute  appendicitis  or  cholecystitis;  in  many  cases  it 
never  disappears  from  one  seizure  to  another.  Again,  in  the  sub- 
acute  and  chronic  cases  of  the  two  above-named  conditions,  as 
well  as  in  lesion^of  other  structures,  an  obscure  symptom  or  group 
of  symptoms  have  tenderness  as  the  most  valuable  guide  to  their 
proper  interpretation. 

Soreness  is  a  second  subhead  under  pain,  which  may  yield 
faithful  aid,  especially  when  considered  as  a  part  of  the  case 
history.  Pain  may  be  present  and  at  the  same  time  violent;  if 
due  to  inflammation,  that  pain  will  have  tenderness  associated  with 
it;  on  subsidence  of  the  acute  symptoms,  and  disappearance  of  all 
pain  and  much  of  the  tenderness,  the  region  involved  is  described 
as  remaining  sore  for  several  hours  or  days,  whether  elicited  by 
active  or  passive  movement  of  the  parts.  After  an  attack  of  in- 
testinal colic,  soreness  does  not  persist  when  the  spasm  is  off;  but, 
if  the  pain  is  due  to  an  inflammation  such  as  acute  appendicitis, 
then  soreness  often  does  persist.  Soreness  and  tenderness  cannot 
be  accepted  as  pathognomonic  symptoms  any  more  than  the 
remainder  of  the  group,  but  their  presence  or  absence  should  al- 
ways be  observed,  since  a  true  understanding  can  often  not  be  had 
without  them. 


INFLAMMATION  115 

In  inflammation  of  those  structures  capable  of  resulting  disas- 
tnmsly,  and  that  in  a  very  short  while,  pain  becomes  not  simply 
a  diagnostic  symptom,  but,  at  the  same  time,  is  one  of  far-reaching 
prognostic  value.  Hence,  no  anodyne  should  be  given  internally 
until  the  diagnosis  is  clear  enough  to  indicate  a  rational  line  of 
action,  and  the  patient  has  agreed  to  the  employment  of  safe  means 
for  his  relief.  The  point  is,  sudden  cessation  of  pain  in  an  overdis- 
t* -in  led,  inflamed  viscus,  such  as  the  appendix,  may  mean  either 
that  the  viscus  has  ruptured,  poured  its  infected  contents  into  the 
peritoneal  cavity,  or  that  it  has  become  gangrenous  and  devoid  of 
sensibility,  a  fatal  turn  in  either  instance,  and  one  that,  however 
the  physician  may  have  looked  upon  the  case  before,  can  now  be 
viewed  only  in  the  light  of  an  urgent  surgical  condition.  If  a 
large  dose  of  morphin  or  other  anodyne  has  been  given  and  the 
pain  relieved,  it  does  not  alter  the  process  going  on  within,  but 
hides  from  the  physician  valuable  information  which  cannot  be 
replaced  until  the  opportune  moment  has  passed.  The  same 
observation  holds  for  other  conditions,  as  we  shall  see. 

(5)  Impaired  Function. — In  every  case  of  inflammation  the 
function  of  the  tissues  or  organs  is  disturbed  hi  some  way,  either 
as  an  overactivity,  or  increased  irritability,  or  as  a  reduction,  in 
a  true  impairment  of  the  function.  In  those  organs  which  have 
two  or  more  functions,  such  as  the  hollow  viscera,  the  disturbance 
may  seem  to  affect  one  function  more  than  the  others,  but,  since 
these  functions  are  complements  one  to  the  other,  the  disturbance 
is  recognized  and  spoken  of  as  unpaired  function.  For  instance, 
one  of  the  functions  of  a  gut  is  to  retain  its  contents  sufficiently 
long  to  digest  and  absorb  the  nutriment  contained  therein,  and  the 
complementary  function  is  that  peristaltic  contractions  shall  re- 
move the  detritus  at  a  rather  fixed  rate.  Thus,  when  the  mucosa 
is  inflamed,  digestion  is  impeded  or  suspended,  the  retaining  power 
of  the  gut  is  reduced  far  below  normal  in  capacity,  and  the  peris- 
taltic motions  are  accelerated  so  that  a  diarrhea  of  varying  inten- 
sity results.  The  former  functions  are  reduced  and  the  latter  in- 
crea-ed.  Likewise,  the  urinary  bladder,  when  inflamed,  loses  its 
power  of  serving  efficiently  as  a  reservoir,  and  must  pass  the  few 
drops  accumulating:  within  it  as  rapidly  as  they  are  deposited  from 
the  urethral  mouths;  a  dribbling,  frequent  urination  is  the  conse- 
quence. 

When  the  eye  becomes  inflamed  its  function  is  reduced  to  an 
extent  that  varies  with  the  intensity  of  the  process  and  with  the 
part  of  the  mechanism  attacked.  Of  course,  the  eye  can  see,  but 
it  cannot  perform  accurately  and  constantly  it-  function  of  seeing; 
in  -even-  cases,  the  moment  light  -trikes  the  retina  a  reflex  hlepha- 


116  PRINCIPLES   OF   SURGERY 

rospasm  is  instituted  and  vision  is  a  practical  impossibility — the 
function  of  the  eye  is  impaired. 

In  the  case  of  articulations  the  function  of  a  joint  may  remain 
in  some  degree,  but  its  motion  is  always  limited  to  some  extent, 
often  in  some  one  direction  more  than  in  others;  this  restriction  is 
positive,  both  in  active  and  passive  motions  of  the  joint,  and  sub- 
sides when  anesthesia  or  narcosis  is  produced,  showing  that  it 
results  directly  from  the  process  of  inflammation  and  not  from  the 
gross  changes  interfering  with  the  mechanism  of  the  joint.  The 
explanation  of  this  phenomenon  will  be  found  a  little  further  on, 
under  the  discussion  of  rigidity. 

The  vocal  cords,  when  inflamed,  cannot  be  made  to  produce 
voice,  or,  if  they  do,  it  is  so  altered  as  not  to  be  recognized  as 
belonging  to  its  owner.  Here  the  disturbance  of  function  partakes 
of  an  additional  etiologic  factor,  namely,  that  there  is  a  thickening 
of  the  cords  sufficient  to  change  the  quality  of  their  notes  or  to 
render  them  silent. 

The  causes  of  unpaired  function  in  inflammation  are  very  defi- 
nite. They  are,  first,  pain  on  function  (sensory) ;  second,  fixation,  if 
motion  be  a  part  of  the  function  (reflex),  due  to  involuntary  rigidity 
or  immobilization  of  the  parts  from  refusal  of  the  muscles  to  yield 
hi  their  normal  manner;  third,  interference  by  swelling  or  by  other 
inflammatory  products,  such  as  exudate,  lymph,  and  the  resultant 
fibrous  or  osseous  organic  changes  of  the  same  (mechanical). 
These  three  factors  may  all  interfere  with  function  in  a  given  case, 
or  any  one  or  two  of  them  may  be  largely  or  wholly  wanting.  Pain 
may  be  responsible  for  impairing  function  by  its  continuous 
presence,  whether  function  is  attempted  in  the  part  or  not;  the 
fixation  due  to  muscular  contraction  may  be  excessive,  with  rela- 
tively little  pain,  although  the  two  seem  to  go  fairly  well  together, 
the  pain  becoming  violent  and  unbearable  when  attempt  is  made 
to  overcome  the  muscular  contraction.  Yet  in  many  cases,  es- 
pecially the  subacute  and  chronic  ones,  the  patient  will  complain 
of  no  pain  until  after  rigidity  of  the  muscles  has  attempted  to  check 
manipulation  from  carrying  the  motion  to  the  painful  point.  This 
shows  conclusively  that  the  reflex  immobilization  is  produced  by 
other  stimuli  than  pain.  It  is  true,  however,  that  this  fixation 
always  holds  the  part  concerned  in  the  position  most  comfortable 
to  the  patient. 

Swelling  need  be  discussed  only  briefly.  It  is  manifestly  an 
interference  with  the  function  of  the  parts  affected,  as  in  the  vocal 
cords  (vide  supra),  in  the  joints,  in  the  mucous  membrane,  and  the 
skin,  where  it  cannot  fail  to  alter  the  function  of  their  glands.  If 
an  exudate  be  present  and  in  considerable  quantities,  as  happens 
in  the  serous  cavities,  then  the  functions  interfered  with  may  be 


INFLAMMATION  1 17 

not  only  that  of  the  organ  affected,  but  any  and  all  those  other 
structures  in  direct  or  indirect  relation  to  the  cavity  containing  said 
exudate,  by  virtue  of  its  distention  of  this  cavity  and  pressure 
upon  such  adjacent  organs,  causing  their  displacement  or  compress- 
ing them  into  limits  too  narrow  for  their  normal  behavior. 

Permanent  impairment  of  function  may  result  from  adhesions 
in  serous  cavities  and  their  ultimate  organization  into  fibrous,  or, 
in  the  articular  spaces,  osseous  tissue.  The  impairment  in  such 
instances  persists  after  subsidence  of  all  inflammation,  and  is  of 
sufficient  frequency  to  be  guarded  against  as  much  as  possible  in  all 
surgery  of  serous  cavities. 

Muscular  Rigidity. — It  is  wise  that  hi  the  study  of  inflammation 
attention  be  called  to  the  extensive  application  of  muscular  rigidity 
in  inflammatory  processes,  whether  a  disturbance  of  function  of  the 
inflamed  structure  is  affected  thereby  or  not.  Mr.  Hilton  taught 
that  the  same  nerve  that  supplies  a  muscle  moving  a  joint  sends 
also  a  filament  to  the  joint  and  one  to  the  skin  covering  the  inser- 
tion of  that  muscle.  So  the  joint  mechanism  is  directly  connected 
by  nerve  supply  with  every  muscle  that  can  move  the  joint. 
Hence,  it  is  easy  to  understand  how  fixation  of  a  joint  may  happen, 
and  that  independent  of  the  patient's  volition  when  the  joint  is 
inflamed.  Similarly,  it  is  easy  to  see  that  the  fixation  is  brought 
about  through  centers  hi  the  cord,  as  the  amount  of  pain  suffered 
has  little  or  nothing  to  do  directly  with  the  fixation.  It  is  simply 
an  associate  symptom.  This  law  of  Hilton's  has  a  far  wider  ap- 
plication now  than  when  laid  down  by  him.  In  inflammation  of 
the  peritoneum,  especially  if  it  is  acute,  the  muscles  of  the  abdomen 
become  rigid,  usually  on  the  side  affected  and  in  the  region  affected, 
but,  if  the  process  be  extensive  or  violent,  the  whole  abdominal 
wall  becomes  board-like  and  respiration  becomes  thoracic,  showing 
that  the  most  important  muscles  of  respiration  have  yielded  to  the 
demand  for  muscular  rigidity.  Thus,  in  cases  of  acute  appendicitis, 
t  he  right  rectus  and  the  right  obliques  and  the  transversalis  become 
rigid.  The  more  violent  the  attack,  the  more  widely  the  rigidity 
extends  from  McBurney's  point.  It  must  not  be  lost  sight  of  here 
that  in  certain  intensely  violent  infections  no  rigidity  is  observed. 
in,  in  severe  inflammation  of  the  pleura  rigidity  of  the  re- 
spiratory muscles  is  found  on  the  same  side,  and  in  inflammatory 
•  li-ease  of  the  vertebrae  the  muscles  moving  them  are  affected 
likewise. 

Fremitus. — \Yhile  fremitus,  recognized  either  by  touch  or  hear- 
ing, is  of  value  in  only  a  few  organs  as  a  diagnostic  sign,  it  is  valu- 
al>le  enough  when  pie-cut  to  deserve  special  mention.  In  inflam- 
mation of  the  pleura,  of  the  peritoneal  covering  of  the  liver,  of  the 
tendon  >heath-  ;  teuo-ynovitis),  ami  of  the  articular  surface-  of  the 


118  PRINCIPLES   OF   SURGERY 

movable  joints  a  grating  vibration  can  be  detected  when  the 
diseased  surfaces  are  rubbed  over  each  other,  as  in  respiration  in  the 
first  two  instances,  and  in  active  or  passive  motion  of  the  parts  in 
the  last  two.  In  arthritis  the  sign  is  so  well  developed  as  some- 
times to  mislead  one  into  the  belief  that  crepitus  is  present  and 
that  a  fracture  is  the  cause  of  it. 

This  fremitus  must  not  be  looked  upon  as  a  sign  of  inflamma- 
tion per  se,  but  rather  as  an  accident  of  inflammation  of  the  above- 
named  structures.  Here,  however,  it  is  of  the  utmost  diagnostic 
importance,  since  by  the  usual  signs  of  inflammation  a  diagnosis 
can  often  not  be  made  with  any  degree  of  satisfaction;  but,  if 
suspicious  signs  present  themselves  and  fremitus  can  be  elicited, 
the  diagnosis  of  inflammation  is  assured. 

Similar  special  but  indirect  evidences  are  of  great,  of  indis- 
pensable value  in  the  recognition  of  obscure  inflammatory  proc- 
esses, arising  in  many  instances  from  disturbance  of  function; 
in  others  from  evidences  found  in  the  secretions  from  the  organ, 
in  others  from  the  presence  and  contents  of  exudates.  Thus,  we 
find  the  contents  of  the  gastric  juice  altered  materially  in  inflam- 
mation of  the  stomach  and  often  a  great  excess  of  mucus.  In  in- 
flammation of  the  mucous  membrane  of  the  intestine  we  find  mucus, 
sometimes  with  the  addition  of  pus  and  blood,  in  the  feces  together 
with  undigested  food.  In  case  of  pancreatitis  its  disturbed  func- 
tion may  be  recognized  by  the  appearance  hi  the  stool  of  fats 
which  have  failed  to  be  acted  upon  by  the  pancreatic  ferments. 
In  inflammation  of  the  kidneys  the  alteration  in  quality  and 
quantity  of  the  urine,  as  well  as  the  appearance  of  definite  micro- 
scopic findings,  shows  the  presence  of  nephritis  often  when  no  local 
or  constitutional  evidence  has  been  observed.  In  meningitis  the 
presence  of  an  excess  of  cerebrospinal  fluid,  together  with  micro- 
scopic or  cultural  discovery  of  the  causative  infection,  leads  to  a 
correct  and  unmistakable  interpretation  of  symptoms  whose  na- 
ture rendered  them  most  perplexing.  Again,  the  appearance  of 
jaundice,  with  little  or  no  associate  diagnostic  symptomatology, 
leads  to  the  knowledge  that  an  infection  is  present  in  the  biliary 
passages. 

These  accidental  signs  are  so  important,  and  so  sure  to  occur  in 
their  special  places,  that  no  diagnosis  of  obscure  conditions  due  to 
infection  can  be  accepted  as  trustworthy  until  all  the  findings  are 
passed  upon.  It  is  often  necessary  to  repeat  the  investigation 
before  the  evidence  sought  can  be  found. 

GENERAL  OR  CONSTITUTIONAL  SYMPTOMS  OF  INFLAMMATION. 
—Inflammatory  processes  may  be  so  limited  or  so  mild  as  to  pro- 
duce no  discoverable  constitutional  impression.  They  may  be  so 
extensive  and  intense  as  to  overwhelm  all  the  reactive  and  defensive 


INFLAMMATION  119 

powers  of  the  body.  They  vary  through  all  degrees  between  these 
extreme.-. 

Fever. — Alteration  of  the  body  temperature  is  the  most  fre- 
quent constitutional  symptom  of  inflammation,  and  the  degree 
and  direction  of  the  change  in  temperature  is  a  splendid  index,  in 
the  usual  infections,  of  the  extent  and  danger  of  the  infection. 

Before  discussing  the  subject  further  it  is  necessary  to  under- 
>tand  the  significance  of  fever  hi  a  general  way.  Once  considered 
an  alarming  condition,  fever  is  now  accepted  as  a  part  of  the  reac- 
tion of  the  body  to  the  infective  cause.  And  so,  instead  of  being 
a  symptom,  to  be  combated  as  such,  it  is  accepted  as  the  most 
reliable  index  to  the  fight  the  body  makes  against  invading  bacteria. 
If,  therefore,  the  temperature  is  reduced  by  artificial  means,  es- 
pecially by  depressing  drugs,  not  only  is  the  guide  to  the  general 
condition  lost,  but  actual  interference  with  the  formation  of  pro- 
tective bodies  may  be  produced.  The  rise  of  temperature  hi  the 
pn-M-nce  of  infection  is  due  to  the  bacterial  poisons  distributed 
throughout  the  general  circulation  from  the  focus  of  infection. 
Increased  chemic  activity  is  produced  by  the  presence  of  toxins 
in  the  blood,  and  reduced  by  removing  the  fluids  or  tissues  whence 
absorption  occurs;  the  temperature  drops  very  soon  after  opening 
an  abscess,  cleaning  out  an  infected  uterus,  or  amputation  of  a 
^anurenous  extremity.  Just  what  role  the  heat  centers  play  in 
the  presence  of  poisons  circulating  hi  the  blood  is  not  known. 
Furthermore,  the  radiation  of  heat  from  the  body  surface,  if  not 
from  the  lungs,  is  reduced,  so  that  the  balance  of  a  normal  tempera- 
tun-  can  no  longer  be  maintained. 

The  rise  of  temperature,  then,  in  inflammation  indicates  the 
extent  of  the  inflammation  and  the  resistance  of  the  patient.  If 
the  vitality  be  normal,  then  a  reaction,  in  the  form  of  fever  ranging 
from  a  slight  rise  to  105°  F.  or  more,  may  be  seen,  and  it  must  be 
rei IK  •inhered  that,  even  with  this  high  degree,  the  fever  is  not  to 
be  looked  upon  as  harmful  in  itself,  but  rather  as  a  reaction  to  a 
harmful  infection. 

<>n  the  contrary,  where  the  resistance  of  the  patient  is  poor 
fr<  »m  disease  or  ago,  and  the  tissues  are  not  able  to  react  sufficiently 
ayain-t  the  poi-on>  taken  into  the  blood;  where,  too,  the  amount  of 
poi-on  i-  so  great  or  its  virulence  so  intense  that  the  resistive  powers 
are  unable  to  cope  with  it,  a  subnormal  temperature  is  observed 
and  the  outlook  is  grave.  Those  patients  overwhelmed  by  over- 
dosage  of  bacterial  poisons  suffer  collapse,  and,  unless  hasty 
removal  of  the  focus  and  active  and  rapid  elimination  of  the 
poi-on-  i-  procured,  de.-ith  en-ue-  -hortly. 

<  )n  withdrawal  of  the  pus  or  other  infected  material  from  which 
the  >upply  of  poison-  is  drawn,  the  protective  bodies  of  the  blood 


120  PRINCIPLES   OF   SURGERY 

and  the  organs  of  elimination  soon  dispose  of  the  poisons  remaining 
in  the  circulation,  and  the  temperature  drops  to  normal,  at  times 
accompanied  by  perspiration  or  diuresis,  occasionally  by  a  diar- 
rhea. The  fall  to  normal  may  be  very  gradual  (lysis)  or  very 
rapid  (crisis). 

The  fever  arising  from  an  ordinary  pyogenic  infection  gaining 
entrance  to  a  wound  comes  up  in  from  eighteen  to  thirty-six  hours 
subsequently.  Inflammatory  fever  is  then  to  be  distinguished  from 
postoperative  fever  or  the  so-called  aseptic  surgical  fever.  Post- 
operative fever  usually  follows  the  larger  surgical  procedures,  and 
does  not  reach  high  grades,  rarely  rising  higher  than  100°  to  101° 
F.  It  comes  up  within  the  first  twelve  to  eighteen  hours  following 
the  operation  and  subsides  by  the  evening  of  the  day  following. 
Aseptic  surgical  fever  is  thought  to  be  due  to  absorption  of  fibrin 
ferment  from  the  wound  surface,  which,  it  is  known,  is  capable 
of  producing  a  rise  of  temperature  when  injected  hypodermically; 
yet  this  rise  of  temperature  probably  is  partially  due  to  bacteria 
gaining  admission  to  the  wound  in  insufficient  numbers  to  estab- 
lish themselves  and  produce  a  local  reaction.  So,  when  a  rise  of 
temperature  comes  immediately  after  an  operation  and  subsides 
by  the  end  of  twenty-four  hours,  it  is  accepted  as  of  no  consequence; 
when  it  comes  at  a  tune  subsequently  to  this  a  search  must  be 
made  for  the  cause,  the  first  step  being  to  investigate  the  wound. 

Chill. — The  surface  of  the  body  may  seem  cold  to  the  patient, 
although  his  temperature  is  above  normal.  This  may  simply  be  a 
dullness,  or  it  may  be  so  marked  as  to  be  a  distinct  chill  or  rigor. 
The  dullness  may  last  for  some  hours  or  be  very  brief,  and  if  a 
chill  comes  it  may  be,  usually  is,  single,  although  it  is  sometimes 
repeated.  There  is  usually  an  initial  chill  in  certain  types  of 
inflammation,  which  is  not  repeated  unless  there  is  an  extension  of 
the  infection,  such  as  happens  at  times  in  erysipelas;  when  such 
extension  occurs  it  is  usually  announced  by  a  more  or  less  distinct 
chill. 

Associated  with  the  fever  of  inflammation  is  the  usual  group  of 
symptoms  found  in  febrile  conditions  generally,  the  febrile  syn- 
drome. This  includes  malaise,  pain  in  the  back,  and  often  in  the 
extremities,  headache,  loss  or  diminution  of  appetite,  constipation 
of  varying  degrees,  unless  the  infection  attacks  the  lining  mem- 
brane of  the  intestine,  when  diarrhea  may  be  present,  and  reduction 
in  the  quantity  and  increase  in  the  color  and  the  specific  gravity 
of  the  urine.  These  symptoms,  associated  with  an  inflammatory 
fever,  are  not  peculiar  to  it,  but  may  happen  in  any  fever,  whether 
produced  by  pathogenic  bacteria  or  not. 

Pulse. — The  pulse  is  accelerated  in  cases  of  inflammation, 
usually  pan  passu  with  the  temperature.  Yet  there  are  exceptions  of 


INFLAMMATION  121 

two  kinds.  In  one  instance  the  temperature  may  run  exceedingly 
high  and  the  pulse  relatively  slow,  as  is  observed  in  inflammation 
of  the  lung  produced  by  the  diplococcus  of  pneumonia,  where  the 
pulse  is  full  and  bounding  and  slow,  of  the  sthenic  type,  or  in  ty- 
phoid infection.  On  the  other  hand,  we  find  cases  of  subnormal 
temperature  with  an  extremely  rapid  and  full  pulse,  observed  in 
those  ill-fated  patients  in  whom  the  balance  between  the  resist- 
ance and  the  infection  cannot  be  maintained,  and  who  are,  there- 
fore, overwhelmed  by  the  virulent  poisons  in  their  circulation. 
Thr  individual  who  has  a  high  temperature  and  a  slow  (relatively) 
pulse  may  be  accepted  as  offering  splendid  resistance  so  far,  but 
the  one  with  low  temperature  (subnormal)  and  a  rapid  and 
perhaps  irregular  pulse  is  to  be  accepted  always  as  being  in  an 
alarming  state. 

Certain  inflammatory  processes  tend  to  produce  different  quali- 
ties in  the  pulse,  a  fact  of  unmistakably  positive  value  at  times, 
but  not  worthy  of  rigid  acceptance.  As  an  illustration  of  this 
point,  the  slow,  full,  bounding  pulse  of  lobar  pneumonia  may 
be  given,  or  the  small,  rapid,  hard,  wiry,  or  thready  pulse  of  acute 
peritonitis.  Again,  the  weak,  scarcely  palpable,  very  rapid,  per- 
haps dichrotic  pulse,  while  belonging  to  no  particular  anatomic 
site,  nevertheless  warns  the  surgeon  of  impending  dissolution. 

The  facies  of  patients  suffering  from  severe  inflammatory 
processes  stand  as  the  equal  of  pulse  and  temperature,  if  not  their 
superior,  as  an  index  to  the  effect  produced  by  the  disease.  There 
is  no  description  worthy  of  the  expression  of  the  countenance  of 
OIK-  violently  intoxicated  with  bacterial  poisons,  but  the  evident 
rapid  loss  of  weight,  the  pinched  expression,  the  unnatural  look, 
the  pallid  features,  the  cyanotic,  livid  lips,  the  leaky  skin,  the 
:inxi(His.  nervous,  uneasy  manner  are  tokens  of  illness  which,  when 
t  hey  have  once  been  seen,  cannot  be  forgotten  and  beggar  all  efforts 
at  description. 

In  severe  inflammatory  processes,  especially  if  they  are  of  long 
duration,  a  distinct  typhoid  condition  may  be  observed,  with  all 
tin-  train  of  nervous  and  mental  symptoms,  developing  subsultus 
tendinum,  carphologia,  coma  vigil,  stupor,  delirium,  coma,  and 
death.  Delirium  may  occur  in  acute  cases  of  very  short  duration, 
as  in  other  febrile  conditions. 

Leukocutoxis. — The  value  of  the  leukocyte  count  as  a  diagnostic 
factor  in  acute  inflammatory  processes  is  well  established,  but 
cannot  be  looked  upon  as  showing  up  in  every  case  with  sufficient 
preciseness  to  render  it  universally  applicable.  It  must  he  accepted 
as  of  not  only  important  diagnostic  service,  but  as  of  prognostic 
importance.  The  rule  is,  that  in  acute  inflammatory  processes 
the  leukocyte  count  often  becomes  the  chief  differential  point 


122  PRINCIPLES   OF   SURGERY 

between  this  condition  and  non-inflammatory  processes.  The 
increase  may  be  so  slight  that  it  has  no  value,  or  the  process  in 
question  may  often  be  associated  with  another  pathologic  process 
which  produces  leukocytosis.  Again,  it  may  be  influenced  by  the 
presence  of  diseases  which  habitually  produce  leukopenia,  conse- 
quently an  increase  of  100  per  cent,  in  the  actual  number  may  be 
observed  without  bringing  the  total  count  up  to  a  maximum  normal. 
In  such  cases,  unless  a  series  of  counts  are  made  at  stated  intervals, 
and  unless  the  leukopenic  process  be  recognized  at  the  time,  mani- 
festly no  importance  could  be  attached  to  the  findings.  So  in 
typhoid  fever,  with  its  usual  leukopenia,  an  acute  inflammatory 
process  may  develop,  and  at  no  time  raise  the  count  above  normal 
for  a  healthy  individual.  However,  if  the  count  be  made  every 
hour  or  two  from  the  time  of  the  suspected  inflammation,  and  the 
alteration  of  the  leukocyte  count  from  hour  to  hour  noted,  rela- 
tively great  variations  may  be  found.  In  acute  inflammations 
the  range  of  leukocytosis  may  run  all  the  way  from  a  worthless 
increase  of  a  few  hundred  cells  to  two  or  five  times  the  normal,  and 
present  such  a  differential  picture  that  it  may  be  accepted  as  almost 
pathognomonic,  even  when  apparently  strongly  contradicted  by 
signs  and  symptoms.  Leukocyte  counts  which  do  not  consider  the 
differential  percentages  cannot  be  relied  upon  implicitly  for  diag- 
nosis, and  have  no  prognostic  value.  However,  if  the  differential 
count  can  be  made  by  a  competent  microscopist  it  gives  valuable 
diagnostic  and  prognostic  information;  in  many  instances  the 
count,  on  the  other  hand,  is  of  little  or  no  value. 

Gibson's  Chart. — Consider  the  normal  number  of  leukocytes  as 
10,000,  and  the  normal  percentage  of  polymorphonuclear  neutro- 
philes  as  75  per  cent.,  both  admittedly  high  maximums,  there  seems 
to  be  a  normal  ratio  maintained  between  the  count  increase  and 
the  percentage  increase.  A  marked  variation  from  this  ratio 
indicates  inability  on  the  part  of  the  body  to  cope  with  the  bacteria 
causing  the  demand.  The  ratio  maintained  with  greatest  advan- 
tage to  the  patient,  according  to  Gibson,  is  that  each  increase  of 
1000  in  the  total  count  should  be  accompanied  by  an  increase  of 
1  in  the  percentage.  Thus,  with  a  total  count  of  20,000  the 
polymorphonuclears  should  be  about  85  per  cent.  The  poly- 
morphonuclears  are  the  phagocytic,  the  anti-infection  cells.  If 
the  percentage  is  high  and  the  total  count  low,  it  is  interpreted  to 
mean  that  the  demand  is  very  great  or  that  the  patient's  resist- 
ance is  poor.  A  paradoxic  fact  is  at  times  found,  in  that  a  very 
limited  inflammation  may  be  seen  with  a  very  marked  leukocytosis, 
and,  vice  versa,  a  very  extensive  process  with  slight  leukocytic  dis- 
turbances. This  may  be  at  least  partially  explained  by  the  rela- 
tionship existing  between  the  resistance  of  the  tissues  and  the 


INFLAMMATION  123 

virulence  of  the  infection.  One  can  but  say,  in  justice  to  the  sub- 
ject.  that,  while  of  the  utmost  importance  as  one  symptom  of  acute 
inflammation,  the  blood  count  cannot  be  relied  upon  as  an  unfailing 
procedure.  Acute  inflammation  has  been  specified  advisedly  in 
tin-  discussion,  for  it  seems  so  far  that  the  leukocyte  findings  are 
of  little  value  in  chronic  processes. 

One  exception  deserves  to  be  made  to  the  above  rule  for  the 
significance  of  the  total  and  differential  counts.  In  cases  of 
abscess  of  the  spleen  the  total  count  is  reduced  far  below  normal 
an<  1  the  lymphocytes  constitute  the  majority  of  the  cells.  Further, 
in  those  cases  where  an  inflammation  is  present,  and  shows  the 
characteristic  leukocyte  changes,  if  a  secondary  involvement  of  the 
spleen  results,  the  same  leukocyte  picture  follows  as  if  the  splenic 
infection  were  primary  (Eppinger). 

Diagnosis  of  Inflammation. — As  a  superficial  process  inflam- 
mation may  usually  be  recognized  without  difficulty.  But  when 
situated  deeply  it  often  becomes  a  veritable  impossibility  to 
clear  away  the  obscurity  hovering  over  the  nature  of  the  lesion. 
The  conditions  causing  confusion  are  numerous — special  affections 
obtain  for  the  various  organs.  In  general,  tumors,  cysts,  and  the 
so-called  granulomata  are  among  the  frequent  causes  of  uncertainty. 
Many  individuals  are  unable  to  give  a  definite  history  of  such  con- 
ditions, and  the  diagnosis  is  thereby  made  more  difficult;  especially 
is  it  difficult  to  penetrate  the  obscurity  in  these  cases  when  an  acute 
inflammation  has  developed  on  such  pre-existing  growths.  Again, 
in  the  case  of  many  constitutional  conditions  it  is  difficult  to  de- 
termine whether  the  symptoms  arise  from  an  obscure  inflammatory 
I  m  H  ess.  Frequently  the  only  method  for  settling  such  uncertainty 
is  to  await  the  appearance  of  diagnostic  symptoms.  The  differenti- 
ation  of  acute  non-inflammatory  painful  processes  in  the  abdomen, 
thorax,  and  cranium  often  present  extreme  difficulty,  especially  if 
a  rise  of  temperature  is  accidentally  or  consequentally  associated 
with  them.  Hence,  many  acute  intra-abdominal  lesions,  intes- 
tinal obstruction,  crises,  enterospasm,  and  neuraliga,  together  with 
the  painful  conditions  growing  out  of  intra-intestinal  conditions, 
pn-ent  such  insurmountable  and  alarming  symptoms  that  a 
timely  interpretation  of  the  case  can  be  given  only  by  exploratory 
sect  it  n\.  I  n  t  he  thorax,  aneurysm  and  tumors  may  cause  hesitancy 
in  eliminating  inflammatory  lesions  and  a  pleurodynia  may  not  be 
distinguishable  from  pleurisy,  if  the  characteristic  friction  sound 
he  obscured  by  adhesions  or  other  causes.  In  the  cranium  and 
spinal  column  the  differentiation  must  be  made  between  affections 
within  and  those  without  the  respective  cavities,  and  between  in- 
flammation, on  the  one  hand,  and  tumor-,  cysts,  hemorrhages, 
aneurysm>,  thromboses,  emboli,  and  depre»ions  on  the  other. 


124  PRINCIPLES   OF   SURGERY 

It  is  safe  to  think  of  inflammation  whenever  an  obscure  lesion  be- 
comes evident,  and  in  most  instances  sufficient  evidence  can  be 
had,  either  by  discovery  of  local  signs,  of  constitutional  symptoms, 
or  of  disturbance  of  function,  sensory,  motor,  or  secretory,  to  un- 
ravel the  mystery,  or  the  failure  of  these  will  eliminate  inflammation 
from  the  question  entirely.  In  spite  of  all,  now  and  then  a  just 
conclusion  can  only  be  reached  after  all  known  means  are  in  a  given 
case  exhausted,  and  far  too  often  no  accurate  conclusion  is  made 
until  the  postmortem  unshrouds  the  mystery  that  has  destroyed 
another  life. 

Prognosis  of  Inflammation. — The  prognosis  of  inflammatory 
processes  depends  on  several  factors.  As  the  preceding  pages  have 
taught,  it  depends  first  on  the  virulence  or  the  nature  of  the  in- 
fection and  the  resistance  of  the  patient.  The  same  poor  protective 
powers  of  a  body  that  have  been  unable  to  ward  off  or  stamp  out  an 
infection  in  its  incipiency  may  succumb  to  the  spread  of  that 
infection  in  its  tissues.  A  slight  infection  of  virulent  bacteria 
may  thus  destroy  tissues  or  life  in  one  who  in  a  better  state  of  health 
might  have  suffered  no  inconvenience  from  it.  The  quantity  of 
the  infection  often  plays  a  prominent  role  in  determining  the 
result.  It  may  be  said  of  the  pyogeriic  cocci  that  for  the  normal 
individual  there  is  a  maximum  dose  which  can  be  overcome  by 
him  without  signs  of  inflammation,  and  that  all  degrees  of  reaction 
will  follow  doses  in  excess  of  this  maximum  until  so  great  a  number 
of  bacteria  are  administered  that  the  resisting  powers  are  over- 
whelmed and  prostration  and  death  follow  in  a  few  hours.  There- 
fore hi  those  cases  where  a  large  abscess  discharges  its  contents 
into  a  cavity  of  great  absorptive  capacity,  such  as  the  peritoneum, 
or  when  a  hollow  viscus  ruptures  and  pours  its  bacteria-laden  fluids 
into  it,  it  will  be  easily  understood  why  the  exitus  is  so  rapid. 

The  general  resistance  of  the  individual  is  not  the  only  item  of 
importance  in  this  connection.  In  practical  work  local  conditions 
often  arise  as  the  result  of  accident  or  of  surgical  procedures  which 
reduce  the  local  resistance  far  below  the  general,  and,  by  making 
it  possible  for  bacteria  to  gain  a  footing  in  this  unresisting  tissue, 
establish  an  infection  which  gives  rise  to  very  serious  consequences. 
Especially  is  this  local  diminution  of  the  protective  power  found 
in  those  cases  where  the  main  blood-supply  is  reduced  to  a  mini- 
mum by  ligation  or  by  trauma. 

The  prognosis  again  depends  on  the  importance  of  the  organ  or 
tissue  affected  in  maintaining  life,  and  on  the  possibility  of  com- 
plications arising  directly  or  indirectly  from  such  a  process. 
The  more  vital  the  structure  affected,  naturally,  the  more  untoward 
the  outlook,  so  that  all  inflammatory  processes  affecting  the  heart, 
lungs,  central  nervous  system,  and  kidneys  are  capable  of  very 


INFLAMMATION  125 

rapidly  terminating  life.  A  process  which  in  muscle  or  bone  might 
-pread  widely  with  only  temporary  discomfort  would  in  a  vital 
organ  or  center  produce  very  early  death.  It  can  be  seen  readily, 
too,  that  if  the  inflammation  is  so  situated  that  by  pressure  of  the 
Duelling  it  could  affect  these  organs  the  same  result  would  follow; 
if  a  thrombus  should  form  from  a  facial  inflammation  and  extend 
i i it  o  t  ho  sinuses  of  the  skull,  or  if  it  should  form  from  proximity  to  an 
extracranial  infection,  as  in  mastoiditis,  it  becomes  a  serious 
n ic -nan  to  life.  If  in  the  course  of  the  circulatory  system  the 
inflammatory  process  should  result  in  the  formation  of  vegetations, 
a-  in  endocarditis,  or  in  thrombus  formation  in  a  comparatively 
safe  region,  as  in  the  femoral  vein,  the  fact  that  these  clots  and 
it  ions  may  at  any  moment  become  dislodged  and  complicate 
a  curable  inflammatory  process  by  a  fatal  embolus  renders  the  dan- 
ui  r  much  more  apparent. 

Treatment  of  Inflammation. — The  treatment  of  inflammation, 
to  l>e  efficient,  must  be  applied  in  harmony  with  the  efforts  under- 
taken by  the  inflammatory  reaction,  as  set  forth  hi  the  definition 
at  the  beginning  of  this  discussion.  It  must  also  embrace  in  cer- 
tain cases  the  relief  of  pain  and  such  general  treatment  as  the 
n -i note  action  of  the  infection  may  demand.  Then  all  therapy 
directed  against  inflammation  (it  would  be  wiser  to  say  infection) 
mu-t  be  such  that  it  will  assist  the  inflammatory  process  in  its  good 
efforts  at  the  prevention  of  such  deleterious  action  and  complica- 
tions as  grow  out  of  the  process  in  a  given  structure;  it  must  elimi- 
nate the  bacteria,  prevent  their  action,  and  spread  and  repair  the 
damage  done  by  them,  or  remove  the  destroyed  or  dangerous 
ti-Mios  completely  from  the  field;  it  must  eliminate  all  factors 
favoring  the  continuance  of  infection.  Since  these  ends  are 
undertaken  by  the  tissues,  and  since  the  chief  means  of  action  is 
hy  the  protective  powers  of  the  circulating  fluids,  all  remedial  in- 
terference must  re-establish  the  circulation  as  well  as  possible  by 
active  or  passive  means,  and  must  bring  these  protective  fluids  to 
and  maintain  them  at  their  highest  efficiency.  Where  experience 
ha-  -hown  that  this  cannot  be  done  satisfactorily,  and  where,  by 
such  a  course  of  action,  the  subsequent  complications  or  the 
n •( •urn-nee  of  attacks  show  that  ultimate  cure  cannot  be  done,  the 
surgeon  may  do  at  a  single  treatment  all  that  is  attempted  by  milder 
method-,  namely,  a  removal  of  the  offending  tissue. 

Tht  treatment  of  inflammation  is  local  and  constitutional. 

LOCAL  TREATMENT. — Removal  of  Cause. — The  first  and,  theo- 
retically, mo-t  »•— i-ntial  item  of  local  treatment  of  inflammation 
is  the  removal  of  the  cause,  namely,  the  offending  bacteria.  Out 
of  thi>  nece— ity  irre\v  the  extensive  use  of  anti-eptic-  in  the  treat- 
ment of  >uch  conditions.  However,  this  treatment  has  fallen 


126  PRINCIPLES   OF   SURGERY 

largely  into  disuse,  since  it  has  been  learned  that  the  antiseptics 
do  not  reach  far  beyond  the  surface  to  which  they  are  applied,  and 
hence,  if  beneficial,  they  are  so  by  some  other  virtue  than  that  of 
antisepsis.  The  good  derived  from  such  treatment  is  chiefly  due 
to  the  counterirritant  property  of  the  antiseptic  used,  or  to  the 
serviceable  effect  of  the  heat  or  cold  of  the  solution  containing  it. 
Aluminum  acetate  and  carbolic  acid  solutions  have  been  used 
extensively,  and  iodin,  alcohol,  and  ichthyol  have  been  used,  but  it 
is  doubtful  if  a  case  could  be  made  out  for  any  of  them  as  giving 
relief  by  its  antiseptic  action  hi  an  established  inflammation,  except 
in  the  case  of  ichthyol  in  erysipelas,  where  it  seems  to  give  appar- 
ently good  results;  how,  we  do  not  know.  The  only  cases  where 
antiseptics  as  such  seem  to  cure  by  destruction  of  bacteria  is  where 
they  are  injected  into  the  tissues.  The  chief  instances  of  this  are 
found  in  the  occasional  abortive  treatment  of  a  beginning  abscess 
by  injection  of  carbolic  acid  and  the  injection  of  formalin  solutions 
into  the  pleural  and  articular  cavities.  Whether  they  serve  hi  these 
cases  by  their  antiseptic  power  exclusively  is  very  doubtful. 

Rest. — This  term  applies  not  only  to  rest  of  the  part  affected, 
but  if  the  process  is  extensive  or  dangerous,  or  if  it  affects  very 
important  organs,  it  must  be  applied  to  the  body  as  a  whole.  It  is 
in  this  sense  a  part  of  the  general  or  constitutional  treatment,  but 
for  conciseness  is  given  here. 

It  is  well  known  that  the  blood-pressure  is  higher  and  the  cir- 
culation (the  number  of  heart-beats)  is  more  active  during  even 
moderate  exercise  than  when  standing  or  sitting,  and  in  these 
attitudes  it  is  more  active  than  when  the  body  is  recumbent. 
Interpreted,  this  simply  means  that  the  blood  is  being  forced 
unnecessarily  against  the  already  stagnant  cells  in  the  field  of 
inflammation,  and  so  renders  the  condition  less  capable  of  taking 
care  of  itself.  If,  by  reducing  the  activity  of  the  body — that  is,  by 
rest — the  number  of  pulsations  can  be  reduced  to  a  minimum, 
and  unnecessary  work  so  removed  from  the  heart,  a  distinct  local 
advantage  will  be  gained,  and  vitality  that  will  possibly  be  needed 
in  the  course  of  the  disease  will  be  conserved.  On  the  contrary,  if 
the  inflammation  is  of  the  asthenic  type,  the  increased  activity, 
though  not  affecting  the  local  process,  will  so  draw  upon  the  poor 
reserve  of  vitality  as  to  prove  an  unquestioned,  perhaps  fatal,  loss. 
Therefore  hi  cases  of  acute  inflammation  it  is  safe  to  say  that  rest, 
if  possible  in  the  recumbent  position,  should  be  enjoined,  and  that 
this  should  be  accompanied  by  prohibition  of  mental  activity,  such 
as  the  attendance  on  business  or  the  visits  of  friends,  and  the  pre- 
vention of  exciting  news,  inasmuch  as  they  all  tend  to  increase  the 
activity  of  the  nervous  system  and  draw  on  the  resistive  powers. 
In  many  cases  of  chronic  inflammation  rest  in  bed  is  not  advisable, 


INFLAMMATION  127 

and  may  even  prove  positively  harmful.  So,  for  example,  no  one 
prefers  to  order  such  for  a  case  of  tuberculous  synovitis  or  osteomy- 
elitis  longer  than  the  circumstances  absolutely  demand.  In  these 
exactly  the  opposite  obtains — bodily  exercise,  with  necessary 
conservation  of  the  diseased  structure,  the  association  of  friends, 
fresh  air,  and  cheerfulness  serve  a  good  purpose. 

Rest  of  the  diseased  organ,  local  rest,  is  likewise  one  of  the  most 
indispensible  items  of  the  local  treatment.  It  must  be  physical 
and  as  much  as  possible  physiologic  rest.  The  patient  must  not 
use  the  part  himself,  nor  must  outside  influences  be  brought  into 
action,  so  as  to  interfere  with  the  reparative  work  going  on.  An  il- 
h ist  ration  of  passive  disturbance  of  an  inflamed  field  is  seen  in  the 
antiquated  method  of  squeezing  an  inflamed  tissue  in  an  effort  to 
force  pus  from  it,  or  in  undue  instrumentation  of  an  inflamed  area, 
as  the  bladder  or  rectum,  or  needlessly  frequent  application  of 
treatments  that  are  at  least  of  questionable  importance.  When  an 
eye  is  inflamed  it  should  be  placed  at  rest  by  preventing  the  per- 
formance of  its  function  of  vision  by  prohibiting  the  use  of  the  eye, 
and  should  have  enforced  prevention  of  its  accidental  use  by  cover- 
ing it  with  an  opaque  dressing  or  by  confinement  in  darkness. 
When  the  larynx  becomes  inflamed  silence  must  be  insisted  upon 
if  the  most  speedy  recovery  is  expected.  This  has  recently  been  em- 
pliasized  by  the  announcement  of  cure  in  several  cases  of  tubercu- 
lar laryngitis  by  tracheotomy.  When  the  stomach  becomes  inflamed 
it  is  given  rest  by  withholding  food  and  substituting  artificial  feed- 
ing, or,  if  food  is  allowed  to  enter  it,  it  is  given  in  small  quan- 
t  it  i» -s  of  fluids  of  the  most  nutritious  kind,  thus  gaining  the  greatest 
benefit  from  the  food  with  the  smallest  exertion  of  the  stomach. 
In  cystitis  the  bladder  is  drained  by  a  self-retaining  catheter  or  by 
cystotomy,  and  thus  the  two  functions  of  that  viscus,  namely, 
uti nt ion  of  urine  for  a  tune  and  its  periodic  evacuation,  are  both 
eliminated.  In  acute  peritonitis  nature  attempts  to  hold  the  con- 
tinuously moving  intestine  in  abeyance  by  rigidity  of  the  ab- 
dominal muscles,  and  this  effort  at  enforced  rest  should  not  be 
thwarted  by  the  administration  of  a  purgative,  which,  if  it  proves 
al>le  to  produce  peristalsis,  will  serve  only  to  scatter  the  infec- 
tion broadcast  or  to  force  additional  intestinal  contents  into  the 
peritoneal  cavity  if  a  perforation  is  present.  In  a  similar  way 
acute  inflammation  of  the  joints  is  splinted  by  nature,  and  meddle- 
M.me  activity  in  efforts  to  manipulate  the  joint  prove  not  only  of  no 
value.  !>ut  are  Capable  of  much  harm.  The  body  as  a  whole  must 
re-t.  and  the  part  affected  must  rest  in  cases  of  acute  inflamma- 
tion. 

If  the  inflammatory  proce—  i<  chronic,  then  the  nature  of  the 
MM  mu-t  determine  whether  bodily  rest  in  l»ed  is  u-eful.  Local 


128  PRINCIPLES   OF   SURGERY 

rest  is  useful  to  a  certain  degree,  but  must  not  be  carried  too  far 
unless  adhesions  are  accepted  as  preferable  or  inevitable.  Passive 
rest  is  not  commendable  in  chronic  inflammations,  certainly  not  in 
all,  for  manipulation  and  massage  hasten  the  recovery  and  diminish 
the  chances  of  untoward  sequelae. 

A  single  additional  statement  is  necessary — after  the  termina- 
tion of  an  acute  inflammation  the  return  to  normal  function  must 
be  guarded  lest  a  recurrence  follow.  It  is  better  to  permit  gradual 
resumption  of  activity  than  to  allow  it  to  be  sudden  and  complete. 

Position:  Elevation. — The  impaired  circulation  of  inflamed 
tissue  is  influenced  by  elements  that  have  no  bearing  on  healthy 
structures.  The  demand  for  a  free  circulation,  the  freest  possible, 
is  the  chief  local  need  in  an  inflammatory  process,  and,  while  the 
circulatory  apparatus  is  able  to  handle  the  return  current  of  blood 
from  the  most  dependent  parts  of  the  normal  body  fairly  well,  the 
least  interference  by  gravity  with  the  venous  return  from  an  in- 


Fig.  14. — Forearm  and  hand  resting  in  elevated   position.      Treatment  of 

inflammation. 

flamed  structure  is  perceptible  to  the  patient  by  the  increase  of  pain 
and  retards  recovery,  or  actually  serves  to  cause  a  severer  termina- 
tion of  the  process  than  would  otherwise  occur.  The  same  is 
true  of  artificial  obstructions,  such  as  garters,  tight  clothing,  or 
bandages  on  the  proximal  side  of  the  lesion,  or  of  pathologic  inter- 
ference, such  as  thrombosis  of  an  important  vein  and  tumors  press- 
ing upon  the  vein.  Hence,  the  dependent  position  of  an  inflamed 
organ  is  to  be  avoided  as  much  as  possible,  and  elevation  sufficient 
to  maintain  an  easy  return  of  the  venous  blood  is  to  be  made.  So 
if  the  foot  is  affected,  the  best  results  are  had  by  lying  in  bed  and 
placing  the  foot  on  a  rest  above  the  level  of  the  body,  comparatively 
moderate  benefit  only  being  derived  from  sitting  with  the  foot  on  a 
level  with  or  a  little  above  the  buttocks.  So  carrying  the  hand  in  a 
sling  is  better  than  allowing  it  to  hang  by  the  side,  but  not  so  good 
as  elevation  to  or  above  the  level  of  the  shoulder. 

Another  application  of  position  demanding  consideration,  and 


INFLAMMATION  129 

imperative  in  practice,  is  that  where  an  inflammatory  process  has 
resulted  in  an  accumulation  of  a  discharge,  whether  serum  or 
pu-.  and  a  vent  for  the  same  has  been  established,  the  position 
mu-t  be  such  as  to  insure  the  freest  and  easiest  discharge  of  the 
Snkb. 

Compression. — Pressure,  or  compression,  may  become  a  useful 
adjuvant  in  the  treatment  of  inflammation.  Support  would 
probably  be  a  better  term  than  either  of  the  above,  for  the  pressure 
is  always  to  be  applied  guardedly.  Pressure  should  be  uniform 
in  its  distribution  over  the  surface  affected,  and  is  accomplished  by 
applying  the  bandages  with  uniform  tension — it  is  difficult  to 
wrap  them  so  that  one  edge  does  not  bind  more  than  the  other. 
( '(impression  is  more  valuable  in  subacute  and  chronic  inflamma- 
tion and  in  the  resolution  of  acute  inflammation  than  during  the 
early  stages  of  the  latter;  for,  if  a  bandage  be  firmly  applied  early, 
and  the  swelling  continues,  severe  damage  may  be  done  before  the 
dre<sing  is  recognized  as  the  cause.  In  the  early  stages  of  inflam- 
mation the  tight  bandage  can  do  no  good  and  is  capable  of  great 
harm.  But  in  those  cases  where  there  is  great  swelling  and 
edema,  and  where  the  process  has  passed  its  height,  a  hastier  return 
to  normal  is  obtained  by  using  compression.  In  cases  where  the 
process  is  subacute  or  chronic  the  application  of  firm  compression 
i<  very  beneficial;  this  statement  holds  true  for  synovitis,  with 
accumulation  of  fluid  in  the  joint  cavity,  as  well  as  elsewhere. 
Compression  has  proved  very  widely  useful  in  the  treatment  of 
epididymitis  after  the  subsidence  of  acute  symptoms.  It  is 
u>ually  accomplished  here  by  the  application  of  an  adhesive  dress- 
ing. As  soon  as  the  dressing  becomes  loose  by  subsidence  of  the 
-welling  under  pressure  it  should  be  reapplied. 

Local  Blood-letting. — By  the  term  "local  blood-letting"  is  meant 
the  withdrawal  of  blood  from  the  affected  region  without  any 
attempt  to  impress  the  general  circulation  thereby  and  thus  indi- 
rectly to  affect  the  inflammatory  process,  but  to  produce  an  im- 
mediate  and  direct  effect  on  the  tissues  concerned.  This  method 
of  treatment,  when  properly  employed,  affords  one  of  the  most 
useful,  grateful,  and  rational  means  of  relief.  The  result  is 
accomplished  by  allowing  a  discharge  of  blood  and  serum  directly 
from  the  painful,  throbbing,  swollen  part.  This  escape  of  fluids 
relieves  tension  more  than  temporarily,  reduces  or  allays  the  pain; 
the  fluids  carry  out  with  them  a  portion,  perhaps  insignificant,  of 
the  bacteria,  ami  -omewhat  of  the  toxins;  this  relieve*  the  engorge- 
ment in  the  v«-»el<  and  the  pressure  from  those  not  affected,  and 
allow-  re>u  mpt  ion  of  a  more  active  circulation  and  the  entrance  into 
the  field  of  action  of  fresh  leukocytes  and  serum  ready  to  combat 
the  remaining  bacteria.  Not  only  BO,  the  continued  flow  of  >erum 

9 


130  PRINCIPLES   OF   SURGERY 

in  greater  or  lesser  quantity  from  the  openings  made  guarantees 
the  maintenance  of  a  fresh  supply  of  antibacterial  substances  for 
some  hours. 

There  are  four  methods  in  use  for  this  purpose: 
(a)    Scarification. — This   method  of  local   blood-letting   is   of 
service  in  limited  inflammations  of  the  mucous  membranes,  and 
could  manifestly  be  of  little  usefulness  in  extensive  processes.     The 
epithelial  covering  is  cut  through  at  several  points  with  a  scarifica- 
tion knife,  with  as  little  trauma  to  the  underlying  tissues  as  possible. 
(6)  Multiple  Puncture. — A  sharp  bistoury  is  employed  here,  and 
several  punctures  are  made  down  into  the  inflammatory  mass, 
reaching  as  deeply  as  the  case  may  demand.     This  method  is 
intended  to  allow  an  escape  of  fluids  from  the  depths  of  the  process. 

(c)  Incision. — If  the  preceding  method  for  any  reason  seems 
inadequate,  incision,  single  or  multiple,  parallel  or  crucial,  is  done 
deep  down  into  the  inflamed  tissues  and  a  large  outlet  is  made. 

(d)  Leeches. — This  is  mentioned  more  as  a  matter  of  complete- 
ness that  from  any  desire  on  the  author's  part  to  recommend  it. 
Yet  there  are  patients  who  will  submit  to  leeching,  though  posi- 
tively refusing  either  of  the  two  preceding  methods.     The  objec- 
tion to  the  use  of  leeches  is  that  they  are  gruesome,  presumably  not 
aseptic,  and  at  times  troublesome  to  handle.    Still  there  are  recent 
texts  by  able  authors  recommending  their  use. 

In  employing  any  of  these  methods  asepsis  is,  of  course,  impera- 
tive. If  one  desires  the  bleeding  to  continue  for  a  time,  it  is  ac- 
complished by  the  use  of  tepid  water  on  the  bleeding  surface  or  by 
the  employment  of  a  dry  cup.  When  it  becomes  necessary  to 
control  the  active  hemorrhage  a  pack  or  compress  and  hot  water  will 
be  sufficient.  If  the  inflammation  is  produced  by  anaerobic  bac- 
teria incision  is  of  utmost  importance,  as  it  serves  the  purpose  of 
treating  the  inflammation  and  crippling  the  bacteria  by  admission 
of  oxygen  at  the  same  time. 

In  the  employment  of  local  blood-letting  surgery  has  its 
most  certain  means  of  aborting  an  inflammation  and  of  preventing 
the  more  undesirable  terminations.  The  course  of  the  inflamma- 
tion is  certain  to  be  curtailed  by  it  and  the  ultimate  tissue  destruc- 
tion will  be  prevented  or  materially  limited. 

Heat  and  Cold. — The  use  of  heat  or  cold,  especially  the  former, 
has  long  been  a  favorite  treatment  for  inflammation.  They  may 
be  used  as  dry  heat  or  cold  and  as  moist  or  wet.  The  latter  method 
has  been  thought  the  more  advantageous,  on  account  of  the 
shriveling  effect  of  prolonged  exposure  of  cutaneous  surfaces  to 
water,  the  appearance  of  the  washerwoman's  hands  after  several 
hours'  service  at  the  tub  being  cited  as  an  illustration  of  this  power. 
In  the  light  of  our  knowledge  of  the  modus  operandi  of  thermal  treat- 


INFLAMMATION  131 

incut,  it  would  seem  indifferent  whether  the  application  is  dry  or 
moi-t.  and  the  only  advantage  of  choice  between  the  two  is  con- 
venience of  application.  The  use  of  poultices,  so  universal  a  few 
years  ago,  had  as  its  chief  recommendation  the  heat  contained  in 
tin-in  and  their  tendency  to  retain  it  a  considerable  time;  and  did 
not,  as  was  thought,  depend  on  any  therapeutic  value  in  bran, 
slippery-elm,  peach-tree  leaves,  flaxseed,  and  so  on.  No  fault  could 
even  now  be  found  with  the  essential  workings  of  treatment  by 
poultice  in  certain  cases,  but  they  are  filthy  and  uncomfortable,  and 
arc  not  only  not  sterile,  as  a  rule  (some  were  shockingly  nasty),  but 
are  favorable  pabulum  for  bacteria.  Some  of  the  modern  poultice 
material  found  in  the  markets  has  the  same  advantage  of  making 
a  moist  dressing,  and  can  be  used  either  hot  or  cold.  About  the 
only  advantage  gained  by  the  drugs  contained  in  them  is  to  render 
and  keep  them  sterile.  But  all  forms  of  poultices  are  to  be  viewed 
as  means  for  applying  moist  heat  or  cold,  nothing  more,  and  this 
can  l>e  done  in  a  simpler,  more  convenient,  and  cleanlier  way  by  the 
use  of  packs,  compresses,  or  towels  which  have  been  saturated  with 
water,  or  by  allowing  the  water  to  run  over  or  by  immersing  the 
part  in  water. 

If  dry  thermal  treatment  is  desired,  the  water-bottle,  coils 
of  tubing  through  which  the  water  flows,  or  the  thermophore  are 
the  most  convenient  means  of  application.  In  the  administration 
of  cold  in  rubber,  glass,  or  metal  vessels  it  is  best  to  have  a  covering 
of  cloth,  or  to  place  a  towel  between  the  receptacle  and  the  skin, 
as  condensation  on  the  surface  dampens  the  skin  and  the  clothing. 
It  is  wiser  in  cases  which  are  likely  to  need  surgical  work  at  any 
moment  to  employ  only  dry  heat  or  cold,  as  the  prolonged  macera- 
tion of  the  tissues  would  render  asepsis  more  difficult  of  accomplish- 
ment. Another  method  of  administering  heat  is  the  hot-air 
chamber;  this  can  be  used  in  those  cases  where  the  parts  can  be 
enclosed  in  the  apparatus.  In  this  method  of  employing  heat 
the  temperature  may  be  brought  to  very  high  limits  without  harm. 
It  is  chiefly  useful  in  chronic  inflammation  of  joints. 

Heat  and  cold  do  not  produce  their  therapeutic  effect  in  a 
mechanical  way,  for,  while  they  possibly  dilate  and  contract  the 
Mood-vessels  much  as  they  do  metal  tubes,  their  chief  action  is  re- 
tlcx  through  the  vasodilators  and  vasoconstrictors,  and  their 
direct  action  is  negligible.  This  is  mentioned  to  emphasize  that  it 
i^  in  it  the  application  of  violent  heat  or  cold  to  the  tissues  that  is 
BMeenry,  l>ut  the  prolonged  application  of  tolerable  degrees.  In 
case  of  heat  there  is  little  danger,  except  in  unconscious  patients; 
'•i>ii-ciitu>  ones  will  complain  of  excesses.  But  in  the  use  of  cold, 
with  its  anesthetic  tendency,  great  harm  may  be  done  by  tempera- 
tures In-low  that  of  melting  ice.  It  must  be  remembered  that  the 


132  PRINCIPLES   OF   SURGERY 

temperature  of  ice,  if  gathered  fresh  in  the  winter  season,  may  be 
very  much  below  the  freezing  point.  To  state  the  facts  tritely,  the 
object  should  be  not  to  cook  the  parts  or  to  freeze  them,  but  to 
stimulate  the  circulation  reflexly  into  greater  activity,  and  moder- 
ate degrees  of  heat  and  cold  are  sufficient. 

When  to  employ  heat -and  when  cold  is  a  difficult  problem,  if, 
indeed,  there  is  a  choice  generally,  except  in  so  far  as  the  comfort 
afforded  may  determine  it.  Some  surgeons  use  heat  and  cold 
alternately,  applying  heat  for  an  hour  or  two  and  cold  for  a  similar 
period.  Since  cold  contracts  the  blood-vessels,  it  would  seem  to  be 
indicated  in  those  stages  of  inflammation  prior  to  stasis,  and  since 
heat  dilates  the  vessels,  it  would  seem  preferable  during  the  latter 
period  of  congestion  and  during  stasis.  But  in  every  inflammation 
these  stages  exist  side  by  side,  and  so  no  choice  could  be  made  on 
such  a  basis,  except  it  be  the  alternation  of  the  two.  In  most  cases 
heat  is  preferred,  but  in  acute  inflammation  of  the  peritoneal 
cavity  and  of  the  testicle  and  epididymis  cold  is  usually  pre- 
ferred. 

Heat  or  cold  may  be  applied  continuously  or  at  intervals,  an 
hour  or  two  on  and  an  equal  tune  off. 

The  use  of  heat  in  acute  inflammatory  processes  about  to  sup- 
purate hastens  the  breaking  down  of  necrotic  tissue  by  its  favorable 
action  on  bacteria  in  areas  where  the  circulation  has  ceased,  and 
limits  the  inflammatory  process  in  the  surrounding  zone  by  stimu- 
lating the  circulation  to  greater  activity.  In  tissues  whose  circu- 
lation is  maintained  it  is  inconceivable  that  the  activity  of  bacteria 
could  be  materially  increased  by  its  application. 

The  danger  in  the  use  of  heat  is  a  burn;  in  the  use  of  cold  there 
is  danger  of  causing  death  of  tissue  by  prolonged  application,  es- 
pecially in  the  very  young  and  the  very  old  and  feeble. 

Counterirritation. — This  method  has  been  employed  in  the 
treatment  of  inflammation  for  ages,  and  its  value  depends  upon  the 
increased  flow  of  blood  to  the  region  affected.  Its  usefulness  is 
chiefly  in  chronic  and  subacute  inflammatory  processes,  although 
it  is  employed  in  certain  acute  processes  with  apparent  benefit. 
Acute  conditions  in  which  Counterirritation  is  used  are  pleurisy, 
lobar  pneumonia  under  certain  circumstances,  and  inflamma- 
tions of  the  mucous  membrane.  One  would  not  think,  however,  of 
employing  it  with  advantage  in  hyperacute  or  fulminating  cases  in 
any  tissue. 

Counterirritation  is  made  by  the  application  of  rubefacients, 
as  illustrated  by  bathing  the  part  in  mustard  water,  or  by  the  ap- 
plication of  mustard  plasters,  by  rubbing  with  turpentine  or  some 
irritating  liniment;  by  the  application  of  iodin  in  some  form,  the 
usual  method,  as  tincture  of  iodin,  compound  iodin  ointment;  by 


INFLAMMATION  133 

the  use  of  other  ointments,  such  as  ointment  of  the  nitrate  of  mer- 
cury; by  blistering  agents,  as  cantharides,  cantharidal  collodion, 
and  other  similarly  acting  drugs;  and  by  the  employment  of  the 
actual  cautery  to  produce  multiple  flying  blisters.  The  applica- 
tion of  the  cautery  is  made  at  points  ^  to  1  inch  apart,  and  over 
a  relatively  wide  area.  No  dressing  is  necessary  except  simply 
covering  the  field  with  dry  sterile  gauze,  and  even  this  is  dis- 
pensable. The  application  of  medicaments  to  soothe  the  pain 
following  is  contra-indicated.  After  a  few  days,  when  scabs  have 
formed  and  are  falling  off,  or  after  the  blisters  are  dried  up,  a  second 
application  may  be  made,  if  necessary,  touching  the  skin  in  the 
intervals  left  from  the  preceding  sitting.  It  is  probably  wiser  to  do 
such  treatment  without  employment  of  anesthesia,  for,  if  one  ad- 
mits that  the  therapeutic  effect  is  the  same,  still  some  importance 
HUM  be  attached  to  the  mental  effect  produced  by  such  treatment. 
It  is  useless  in  all  cases  where  necrosis  or  suppuration  has  occurred, 
and  finds  its  best  field  in  deep  inflammations,  such  as  periostitis, 
synovitis,  arthritis,  and  inflammatory  processes  in  the  muscles  or 
ligaments  of  the  back. 

Counterirritation,  carried  to  the  extent  of  producing  large 
blisters,  has  the  additional  effect  of  withdrawing  considerable 
quantities  of  fluid  from  the  blood. 

The  so-called  resolvent  drugs  have  probably  no  effect  beyond 
that  of  mild  counterirritation.  Those  drugs  which  are  mixed 
with  counterirritants  are  intended  to  produce  some  adjuvant  effect 
— aconite  and  iodin  are  used,  and  aconite,  iodin,  and  opium  are 
used  in  combination  to  dilate  the  vessels  and  to  allay  pain.  The 
cooling  lotions,  once  very  extensively  in  vogue,  had  the  same  effect 
as  the  employment  of  moderate  cold. 

Massage. — In  acute  inflammation  massage  must  be  accepted 
as  having  only  a  harmful  effect.  The  more  acute  the  process  the 
more  peremptorily  is  it  contra-indicated,  for  the  reasons  assigned 
umler  Rest.  However,  after  the  acute  stages  have  passed,  and  in 
suhacutc  and  chronic  inflammation,  it  has  very  decided  usefulness. 
MM— age  stimulates  the  circulation,  breaks  up  new-formed  tissue 
and  encourages  its  absorption,  and  prevents  thereby  sequelae  in 
the  nature  of  adhesions  or  ankylosis.  It  is  of  greater  value  when 
u-ed  in  conjunction  with  counterirritation,  or  with  the  application 
of  moi-t  heat  by  immer-ion  of  the  part  in  water  heated  to  tolerance, 
and  the  performance  of  massage  during  or  immediately  subsequent 
to  tlie  immersion.  Manage  may  be  accompanied  by  a  certain 
amount  of  phy-iologio  use  of  the  part,  which  accomplishes  the 
same  end.  and  lireets  the  result  along  useful  lines.  So,  for  ex- 
ample, in  inflammations  of  the  hand  the  resulting  stiffness  may  be 
overcome  by  the  persevering  practice  of  the  patient  in  squeezing 


134  PRINCIPLES    OF   SURGERY 

a  hollow  rubber  ball.  In  the  after-treatment  of  adhesions  follow- 
ing extensive  peritonitis  the  constant  stimulation  of  peristalsis  by 
the  use  of  laxatives  is  nothing  more  than  a  physiologic  massage  of 
the  intestines,  and  the  constant  traction  and  rubbing  of  the  ad- 
hesions not  only  lengthens  them,  but  causes  their  absorption,  so 
that  in  subsequent  laparotomies  a  surprisingly  small  vestige  of 
some  former  violent  and  extensive  peritoneal  infection,  with  its 
great  outpour  of  lymph,  is  observed. 

Hygroscopic  Drugs. — If  an  inflammation  is  on  or  near  a  mucous 
membrane  the  local  application  of  hygroscopic  drugs  is  of  decided 
value.  The  special  field  of  usefulness  for  this  class  is  in  the  treat- 
ment of  inflammation  of  the  organs  of  the  female  pelvis  by  vaginal 
tamponade.  The  drug  most  widely  used  is  glycerin,  usually  con- 
taining an  admixture  of  boroglycerid  or  ichthyol.  By  the  use  of 
this  treatment  fluids  are  drawn  from  the  region,  and  subsequent 
improvement  may  be  expected;  it  depletes  the  parts. 

Bier's  Hyperemic  Treatment. — Under  the  name  of  hyperemic 
treatment  Bier  has  grouped  a  number  of  older  methods  of  treat- 
ment of  inflammation,  elaborated  them,  added  much  that  is  new, 
and  given  the  reasons  for  the  success  of  the  methods  which  have 
become  the  explanation  of  the  success  of  other  treatments;  he 
has  shown  that  it  is  by  bringing  leukocytes  and  fresh  serum  to  the 
diseased  tissue  that  a  cure  is  brought  about.  In  other  words,  he 
practises  artificially  as  close  an  imitation  as  possible  of  what  nature 
undertakes  in  the  relief  of  inflammation.  It  is  of  necessity  true 
that  all  successful  methods  for  treating  inflammation  accomplish 
their  end  by  bringing  the  antibacterial  properties  of  the  tissues  into 
play.  In  untreated  inflammation  they  are  delivered  by  the  cir- 
culation (active  hyperemia):  they  are  delivered  in  increased  pro- 
portions under  the  influence  of  heat,  cold,  counterirritations, 
massage,  and  position,  because  of  the  ability  of  these  methods  to 
stimulate  the  circulation,  favorably  modify  the  lumina  of  the 
vessels,  or  reduce  the  resistance  to  blood  circulation  by  facilitating 
venous  return.  The  same  end  is  accomplished  in  Bier's  method. 
In  the  cure  of  inflammation,  not  only  must  the  bacteria  be  elimi- 
nated and  the  tissues  returned  to  their  normal  state,  but  the  toxins, 
which  are  more  abundant  at  the  site  of  infection  than  elsewhere, 
must  be  disposed  of.  Since  these  bacterial  poisons  produce  the 
constitutional  symptoms  present,  it  becomes  evident  that  there 
are  certain  conditions  under  which  it  would  be  unwise  to  produce 
passive  hyperemia;  and,  after  overfilling  the  tissues  with  blood  and 
serum  suddenly,  to  turn  this  fluid  again  into  the  general  circulation, 
since  the  general  resistance  would  not  be  able  to  cope  with  the 
increased  quantity  of  toxins  whatever  the  fate  of  the  bacteria  which 
produced  them  might  be.  So  many  toxins  may  be  turned  into  the 


INFLAMMATION 


135 


circulation  as  to  produce  a  fatal  result,  even  though  all  bacteria 
might  be  destroyed.     This  is  one  danger  to  be  guarded  against  in 


Fig.  15.— Bier's  hyperemic  treatment — cupping. 

pa— ive  hyperemia.     Again,  when  the  tissues  are  swollen  to  the 
limit,  and  when  there  is  evidence  of  impending  necrosis,  one  can 


Fin-  10. — Bier's  hypcn-mic  trrut  merit — tourniquet. 

see  how  passive  hyperemia  of  slight  degree  and  of  short  duration 

would  tend  to  hasten,  if  not  positively  determine,  ^ngn-iu-  of  the 
part.     Hence,  if  Bier's  treatment  is  to  bi  applied  in  cases  of  infec- 


136 


PRINCIPLES   OF   SURGERY 


tion  which  present  general  symptoms  of  high  toxicity,  or  in  those 
where  a  dissolution  of  the  tissues  is  imminent,  the  treatment  should 
be  administered  either  not  at  all  or  with  the  utmost  caution,  or 
should  be  preceded  by  incision  of  the  parts,  so  that  an  escape  of  the 
accumulating  toxin-laden  fluids  may  take  place  almost  as  rapidly 
as  they  accumulate,  thus  giving  in  an  intensified  manner  the  same 
results  already  seen  from  local  blood-letting. 

The  methods  suggested  by  Bier  for  producing  hyperemia  are 
negative  pressure  or  cupping,  obstruction  of  the  venous  return  by 
compression  with  circular  bandages  or  tourniquets,  both  producing 


Fig.  17. — Bier's  hyperemic  treatment — hot-air  cabinet. 

passive  hyperemia,  and  the  application  of  heat,  as  in  hot-air  cham- 
bers (active  hyperemia). 

The  duration  of  each  treatment,  the  frequency  of  treatment, 
and  the  extent  of  pressure  used  vary  with  the  conditions  present. 
The  treatment  by  passive  hyperemia  may  be  given  in  sittings  of 
from  one-half  hour  to  twenty  hours  per  day.  In  the  acute  cases  the 
sittings  are  relatively  longer,  while  they  are  shorter  in  the  chronic 
processes.  It  is  necessary  to  release  the  pressure  at  intervals, 
allowing  a  rest  of  a  few  minutes  between.  Thus,  in  a  case  of  acute 
superficial  abscess  forty-five  minutes  daily  may  be  consumed, 
applying  the  cup,  retaining  it  five  minutes,  remove  it,  rest  three 
minutes,  reapply,  and  so  on.  Treatment  may  be  made  daily,  twice 
daily,  or  every  other  day,  as  the  case  may  be.  Hot-air  hyperemia 


INFLAMMATION  137 

(active)  is  more  useful  in  chronic  inflammatory  processes  and  in 
cases  where  considerable  exudate  remains  to  be  absorbed. 

Local  Anodynes. — When  the  pain  persists,  in  spite  of  the  treat- 
ment of  inflammation  as  outlined  above,  all  of  which  should  tend 
to  alleviate  the  pain,  it  becomes  necessary  to  resort  to  drugs  for 
relief.  These,  however,  should  not  displace  the  curative  treatment, 
which  should  be  tried  faithfully,  if  possible,  before  resort  is  had  to 
anodynes,  for  usually  the  employment  of  rest,  elevation,  heat  or 
cold,  and  local  blood-letting  will  give  sufficient  relief  to  render  the 
use  of  anodynes  superfluous.  When,  owing  to  the  location  of  the 
inflammation  or  for  other  reasons,  the  pain  persists  or  increases,  no 
hrsitance  need  be  had  in  attempting  relief  by  topical  applications. 
The  drugs  of  most  efficient  service  are  opium  and  its  derivatives, 
belladonna,  frequently  used  hi  combination  with  the  former  drug, 
and  tincture  of  conium.  Cocain  is  also  highly  efficacious,  but  it 
must  be  remembered  that  habit  of  this  drug  is  quite  as  frequent  by 
local  as  by  hypodermic  or  internal  administration,  and  that  the  be- 
ginning of  most  cases  is  a  physician's  prescription.  The  use  of  lauda- 
num and  belladonna  may  give  satisfactory  results  by  application 
to  an  inflamed  skin  surface,  but  the  most  beneficial  results  are 
obtained  by  applying  them  to  mucous  membrane.  The  special 
region  where  pain  is  most  satisfactorily  relieved  by  belladonna  and 
opium  is  in  inflammations  of  the  rectum  and  anus,  and  in  the  deep 
urethra  and  the  base  and  neck  of  the  bladder,  in  which  region  they 
a  n  •  a d  1 1 1  i  nistered  with  most  grateful  comfort  to  the  patient.  They 
arc  to  be  administered  here  in  the  form  of  suppositories. 

There  is  still  another  drug  recently  come  into  repute  as  not 
only  a  relief  for  the  pain  of  inflammation,  but  as  a  curative  treat- 
ment, namely,  magnesium  sulphate.  It  is  employed  in  super- 
ficial infections,  and  is  applied  in  saturated  solution,  which  is 
poured  on  the  dressing  sufficiently  to  keep  it  wet.  The  pain  is 
mitigated,  often  to  the  extent  of  comfort,  and  the  inflammation  is 
shortened,  and  complications  and  untoward  terminations  are  less 
likely  to  occur.  Manifestly,  it  would  be  of  no  service  in  lesions 
widely  separated  from  the  surfaces  of  application. 

<  iKNERAL  OR  CONSTITUTIONAL  TREATMENT  OF  INFLAMMATION. 

— (a)  Increase  of  elimination  may  be  taken  as  the  first  step  in  the 
constitutional  treatment.  The  secretory  and  excretory  organs 
must  IK- brought  to  their  greatest  efficiency.  The  administration  of 
purgatives,  of  diuretics,  and  the  production  of  diaphoresis  are 
the  three  lines  along  which  we  may  work.  There  will  result,  not 
only  an  elimination  of  harmful  products,  but  the  organs  of  the  body 
will  be  placed  at  the  greatest  advantage  in  the  performance  of  their 
nutritive  function.  There  is  no  need  to  undertake  elimination  by 
all  three  routes,  but,  under  ordinary  circumstance-*,  the  alimentary 


138  PRINCIPLES   OF   SURGERY 

tract  and  the  kidneys  are  impressed  into  extra  service.  A  purga- 
tive is  given,  and  large  quantities  of  water  are  administered;  hot 
water  is  a  more  serviceable  diuretic.  If  for  good  reason  any  one  of 
these  three  routes  cannot  be  safely  stimulated  to  higher  activity, 
or  if  it  is  necessary  to  relieve  it  of  as  much  work  as  possible,  the 
other  two  may  be  used.  So  in  cases  where  the  peritoneum  is 
inflamed,  purgatives  will  disturb  the  rest  of  the  tissues,  and,  by 
exciting  peristalsis,  will  intensify  the  inflammatory  process. 
Hence,  the  kidneys  and  the  skin  only  of  the  three  methods  may  be 
employed  in  these  cases.  If  the  inflammation  affects  the  mucous 
membrane  of  the  stomach  or  intestine,  then  vomiting  or  purgation 
at  the  beginning  is  necessary  to  remove  the  contents  and  afford 
rest.  If  the  inflammation  is  in  the  kidneys,  their  work  must  be 
undertaken  by  the  skin  and  bowels,  but,  under  no  circumstances, 
by  attempting  to  drive  the  kidneys  to  perform  excessive  work  in 
their  crippled  condition.  The  physician  is  easily  at  a  disadvantage 
when  one  of  the  eliminative  organs  is  crippled  by  the  disease  he  is 
attempting  to  treat. 

(6)  Increase  in  the  General  Resistance. — The  bodily  vigor  should 
be  brought  to  and  maintained  at  its  highest  efficiency.  Hence  the 
food,  both  in  quantity  and  quality,  must  be  such  as  to  accomplish 
the  end  desired  without  undue  or  unnecessary  exaggeration  of  any 
symptom.  Where  the  sufferer  is  in  poor  health,  anemic,  and  ema- 
ciated— i.  e.,  in  the  asthenic  type — the  administration  of  the  most 
nutritious  food,  in  the  most  easily  assimilable  forms,  and  in  as  great 
quantities  as  can  be  absorbed,  together  with  tonics  and  stimulants 
pro  re  nata,  is  the  line  needful  for  the  best  results.  In  such  cases 
the  blood  is  scant  or  poor  in  quality,  the  blood-pressure  low,  and  the 
pulse  rapid;  the  heart  is  wearing  itself  out  in  the  effort  to  meet  the 
demand  with  an  inadequate  machinery.  In  such  cases  purgation 
must  be  mild,  if  at  all  admissible.  In  the  sthenic  type,  on  the 
contrary,  general  symptoms  are  brought  out  with  such  vehemence 
as  to  thwart  their  very  purpose  by  their  intensity.  The  blood- 
pressure  is  high,  and  the  heart  may  become  exhausted  working 
against  an  undue  backward  pressure.  Here  the  food  must  be 
light,  of  non-stimulating  character,  and  given  in  small  quantity. 
Elimination  may  be  actively  employed,  especially  by  purging,  and 
the  blood-pressure  may  even  be  cautiously  reduced  by  the  adminis- 
tration of  drugs.  There  is  no  place  for  stimulants  in  these  cases 
unless  exhaustion  is  apparent. 

(c)  Increase  of  Specific  Resistance. — The  greatest  advance  of 
recent  times  in  the  control  of  infections  is  the  ability  to  raise  the 
resistance  of  the  individual  against  an  infection  with  which  he  may 
be  afflicted,  or  to  absolutely  fortify  his  body  against  any  further 
evil  from  such  infection.  In  the  administration  of  antitoxins  the 


INFLAMMATION  139 

latter  end  is  reached,  and,  though  the  number  of  bacterial  species 
against  which  such  therapy  is  potent  is  small,  nevertheless  the 
roults  are  astounding.  The  method  of  raising  the  specific  resist- 
ance is  best  illustrated  in  the  treatment  of  inflammation  pro- 
duced by  the  Klebs-Loffler  bacillus.  If  the  toxins  have  not  already 
overwhelmed  the  nervous  centers,  it  may  be  considered  an  unfailing 
cure.  On  the  other  hand,  there  are  many  species  of  bacteria  against 
which  the  resistance  may  be  gradually  raised.  In  violently  acute 
infections  this  method  is,  unfortunately,  worthless,  for  the  poisons 
are  so  abundant  and  their  action  is  so  swift  that  no  dependence 
can  be  placed  in  the  increase  of  protective  bodies;  the  patient  dies 
before  they  can  be  brought  into  action.  But  in  the  less  violent 
acute  cases,  in  recurrent  acute  infections,  in  the  subacute  and 
chronic  cases,  many  infections  are  more  satisfactorily  combated 
thus  than  in  any  other  way.  The  method  is  more  satisfactory  if 
the  usual  means  of  treatment  are  used  conjointly.  The  resistance 
is  raised  by  the  administration  of  vaccines,  the  methods  of  ad- 
ministration and  the  actions  of  which  have  been  explained  in  a 
previous  chapter. 

OPERATIVE  TREATMENT. — When,  by  experience,  it  has  been 
learned  that  an  inflammatory  process  once  established  in  an  organ 
cannot  be  safely  cured  by  the  non-operative  methods,  and  that  the 
process  persists  as  a  chronic  inflammation,  or  in  spite  of  apparent 
recovery,  relapses  or  recurrences  are  very  likely  to  occur  or  in  a 
special  case  have  occurred;  where  complications  and  sequelae  follow 
with  sufficient  frequency  to  render  non-operative  methods  danger- 
ous, and  when  these  methods  fail  entirely  to  give  relief,  operative 
treatment  is  indicated,  either  at  once,  without  resort  to  the  usual 
methods  of  treatment,  or,  if  they  are  satisfactory  for  the  acute 
attack,  the  operation  may  be  done  subsequently.  Empirically, 
-ur^eons  have  learned  in  what  conditions  the  operative  is  to  super- 
sede non-operative  treatment.  The  most  notable  instance  of 
frequent  demand  for  operative  treatment  of  inflammatory  processes, 
either  without  resort  to  non-operative  or  after  the  benefits  of  the 
latter  have  been  obtained,  is  appendicitis,  for  which  the  only 
rational  treatment  is  appendectomy  at  as  early  a  moment  as 
po— il.le;  chronic  inflammation  of  the  uterine  appendages,  acute  or 
chronic  pancreatitis,  or  cholecystitis  and  acute  osteomyelitis  and 
epiphy.-it  i>.  In  application  of  operative  conditions  rare  judgment 
U  necessary  to  determine  at  what  stage  of  the  process  it  is  necessary* 
to  operate.  However,  with  the  exception  of  the  pelvic  viscera,  it 
may  he  tfiven  as  a  safe  guide  that  the  sooner  after  the  diagnosis  is 
made  the  surer  the  chance  of  cure  by  resort  to  open  surgical  pro- 
cedure. 


CHAPTER  V 
SUPPURATION 

SUPPURATION  is  the  formation  of  pus  on  or  in  the  tissues,  and 
is  in  practical  work  always  the  result  of  infection.  Bacteria  capable 
of  producing  pus  are  called  pyogenic  germs,  and,  while  many  bac- 
teria may  produce  disease  without  the  production  of  inflammation 
and  pus,  all  the  pyogenic  germs  are  capable  of  producing  inflamma- 
tion. It  may  further  be  stated  that  pus  can  be  formed  in  the 
tissues  only  as  a  result  of  the  inflammatory  process.  Exceptions 
are  produced  experimentally  by  the  hypodermic  injection  of  croton 
oil  or  turpentine,  but  they  have  no  bearing  upon  practical  pathol- 
ogy and  surgery.  Injection  of  sterilized  pus  and  of  the  filtrate 
from  it  produces  suppuration;  the  toxic  products  of  a  few  of  the 
saprophytes  may  likewise  cause  pus-formation  when  deposited 
in  the  subcutaneous  tissues. 

Definition. — Pus  is  a  creamy  fluid  of  yellow  or  greenish-yellow 
color,  of  alkaline  reaction,  and  having  a  specific  gravity  of  1030  to 
1033. 

The  above  description  is  that  of  the  "good,  laudable  pus"  of 
the  fathers,  who  considered  its  appearance  in  a  healing  wound  as  a 
very  favorable  sign.  But  these  terms  are  no  longer  applicable — 
pus  is  neither  good  nor  laudable. 

The  reaction  of  pus  is  usually  alkaline,  but  at  times  is  neutral 
or  faintly  acid.  Acid  pus  is  found  in  old  cerebral  abscesses,  but  is 
not  confined  to  these. 

Pus  is  frequently  malodorous,  and  this  odor  is  due  to  the  pres- 
ence of  some  particular  organism,  as  the  colon  bacillus,  or  to  a 
mixed  infection  which  causes  decomposition.  The  odor  is  due  to 
formation  of  hydrogen  sulphid,  butyric,  lactic,  and  valerianic  acids. 

Varieties. — There  are  several  varieties  of  pus:  (a)  Pus,  or  nor- 
mal pus,  the  "good,  laudable  pus"  described  above,  (b)  Ichorous 
pus,  which  has  an  unusually  small  percentage  of  solids,  and  is 
acrid  and  irritating  to  the  integument  if  allowed  to  remain  long  in 
contact  with  it.  (c)  Sanious  pus,  which  contains  enough  red  blood- 
cells  or  hemoglobin  to  give  it  a  reddish  or  blood-stained  appearance. 
A  red  pus  has  been  described  by  Ferchmin,  the  color  depending  on 
pigment  produced  by  an  unnamed  bacterium;  the  red  is  bright,  like 
the  color  of  blood,  and  later  changes  to  violet,  (d)  Fetid  pus  is 
self-descriptive;  the  odor  may  be  produced  by  the  pyogenic  bac- 

140 


SUPPURATION 


141 


teria  or  by  infection  with  the  bacteria  of  decomposition.  Pus 
found  in  connection  with  the  lower  alimentary  tract  and  in  the 
I >t -lineal  region  is  especially  likely  to  be  fetid.  This  is  more  often 
but  not  invariably  so  when  a  perforation  has  occurred  during  or 
preceding  abscess  formation,  (e)  Blue,  green,  or  cerulean  pus  is 
due  to  infection  with  Bacillus  pyocyaneus  (q.  v.).  (/)  Sterile  pus 
is  occasionally  seen,  but  in  practical  work  all  of  it  is  considered 
infected. 

Liquor  Puns. — On  allowing  pus  to  stand  for  a  time  in  a  jar  it 
separates  into  an  upper  fluid  layer  and  a  nether  layer  of  solids. 
About  85  to  90  per  cent,  of  pus  is  fluid. 
The  fluid  portion  of  pus  is  called  liquor 
puris,  and  is  a  watery,  straw-colored,  or 
dear  fluid.  It  is  derived  from  blood- 
plasma  and  from  the  fluids  resultant 
upon  the  peptonization  of  tissues  by 
bacteria.  Liquor  puris  contains,  in  ad- 
dition to  the  toxins  of  the  bacteria  con- 
stituting the  infection,  fats,  globulin, 
allmmoses,  tyrosin,  leucin,  mucus,  and 
cholesterin.  The  latter  is  found  par- 
ticularly in  old  pus.  No  fibrinogen  is 
found,  but  in  it  are  found  bactericidal 
and  digestive  substances  and  ferments, 
\vhose  origin  is  attributable  to  the  tissue 
cells  and  to  the  bacteria.  The  salts  of 
-odium,  calcium,  and  magnesium  are 
found,  the  former  in  the  form  of  chlorids 
and  the  latter  in  the  form  of  the  two 
phosphates.  Liquor  puris  could  not  be 
supposed  to  be  entirely  free  from  bac- 
teria, owing  to  imperfect  sedimentation. 
Debris.— The  debris  (or  solids)  of  pus 
contains  large  numbers  of  leukocytes, 
chiefly  polymorphonuclear,  which  may 
or  may  not  contain  bacteria,  the  gran- 
ular mat erial  remaining  after  all  (leukocytes  chiefly)  disintegration; 
the  shred-  and  fragments  of  tissues,  characteristic  often  of  the 
>ite  of  pus  formation,  red  blood-cells,  which  are  accidental,  and, 
mo>t  important  of  all,  bacteria. 

If  the  -uppurative  process  occurred  in  a  region  abounding  in 
fat.  >ufficient  quant  it  ie-  of  it  may  he  present  t  o  float  as  globules  on 
the  -urt'ace  of  the  discharged  pus. 

In  ^a-o.ircuic  ipyouenic  infections)  gas  is  formed  during  the 
development  of  the  infection,  but  escapes  at  the  time  of  incision. 


Fig.  18. — Bottle  of  pus 
separated  into  ddbris  and 
liquor  puris. 


142  PRINCIPLES   OF   SURGERY 

This  is  not  the  only  instance,  however,  in  which  tympanitic 
abscesses  appear;  they  may  appear  as  the  result  of  infection,  but 
especially  trauma  plus  infection  in  connection  with  or  in  proximity 
to  the  alimentary  and  respiratory  tracts. 

Pus  is  produced  by  the  peptonizing  action  of  bacteria  on  the 
tissues,  and  in  by  far  the  majority  of  cases  the  bacteria  responsible 
for  pus-formation  are  the  staphylococci,  which,  as  a  rule,  cause  a 
localized  suppuration,  as  seen  in  acute  abscess.  Streptococci  are 
less  likely  to  produce  pus;  they  produce  a  spreading  inflammation, 
usually  rapid  and  extensive;  however,  streptococci  do  cause  sup- 
puration, especially  if  the  inflammation  continues  for  several 
days.  The  peptonizing  action  of  streptococci  is  more  marked 
when  their  culture  is  more  or  less  deprived  of  oxygen.  Although 
the  above-mentioned  bacteria  are  responsible  for  the  vast  majority 
of  primary  suppurative  processes,  and  for  suppuration  following 
upon  some  primary  non-pyogenic  infection,  there  are  a  goodly 
number  of  bacteria  occasionally  producing  suppuration,  and  a  few 
which,  though  often  producing  disease,  rarely  cause  suppuration 
in  pure  culture.  After  the  staphylococci  the  most  frequent  pus- 
producer  is  the  diplococcus  of  pneumonia,  and,  like  the  pyogenic 
cocci,  it  is  not  selective  in  its  action  upon  the  tissues,  but  may 
affect  bone,  soft  tissues,  and  the  serous  cavities  alike.  Bacillus 
pyocyaneus  is  an  occasional  cause  of  suppuration,  being  character- 
ized by  the  cerulean  hue  seen  in  its  cultures.  Bacillus  coli  com- 
munis  is  often  found  in  mixed  or  pure  culture  in  suppurative  proc- 
esses in  or  near  the  alimentary  tract,  and  is  found  particularly  in 
suppuration  of  the  bile-tracts,  as  in  cholangitis  and  hepatic  abscess. 
Bacillus  typhosus  now  and  then  produces  a  suppurative  process, 
often  some  time  subsequent  to  symptomatic  recovery  from  typhoid 
fever.  The  bacillus  may  lie  dormant  for  months  or  years,  and  then 
cause  abscess  or  empyema,  giving  pure  culture  on  investigation. 
The  parts  usually  affected  are  bones,  cartilage,  and  the  biliary 
tract;  other  tissues  are  occasionally  affected  by  it.  The  infections 
thus  arising  from  Bacillus  typhosus  are  difficult  to  manage,  both 
from  the  standpoint  of  treatment  and  from  the  prophylactic  stand- 
point, as  all  of  them  are  typhoid  carriers,  and,  unless  the  nature  of 
the  infection  be  suspected  from  the  history,  a  wide  distribution  may 
occur  before  its  source  is  determined.  The  bacillus  of  anthrax  and 
some  of  the  micrococci  have  also  been  shown  to  be  occasionally 
pyogenic.  In  addition  to  the  bacteria,  which  are  habitually  or 
rarely  pyogenic,  it  is  well  to  remember  that  certain  fungi  produce 
suppuration;  of  these  the  most  important  are  actinomj'ces,  blasto- 
myces,  Oidium  albicans,  sporotrichia,  and  Trichophyton  tonsurans. 
Secondary  infections  may  occur  in  cultures  of  fungi  the  same  as  in 
those  of  bacteria. 


SUPPURATION  143 

The  puruloid  material  found  in  cold  abscesses  is  frequently 
called  tubercular  pus.  It  is  distinct  from  the  pus  of  acute  infec- 
tions, and  is  usually  very  characteristic,  and  easily  recognizable 
once  one  is  acquainted  with  it.  It  is  formed  by  the  breaking  down 
of  caseous  material  and  the  addition  of  leukocytes  and  fluids  from 
t  h»-  tissues.  It  is  of  a  lighter  color,  usually  almost  white,  is  thinner 
than  ordinary  pus,  and  contains  masses  or  lumps  of  undissolved 
caseous  matter,  a  fact  of  great  practical  value,  as  the  lumps  are  a 
frequent  hindrance  hi  efforts  at  aspiration  of  cold  abscesses.  The 
fact  that  tubercular  pus,  when  coming  into  contact  with  serous  or 
wound  surfaces,  does  not  cause  acute  inflammation  and  prevent 
healing  per  primam  does  not  argue  that  such  pus  is  sterile.  On  the 
contrary,  most  dangerous  infection  may  result  from  such  an  acci- 
dent. Cultures  and  inoculations  always  demonstrate  the  presence 
of  Bacillus  tuberculosis. 

PUS  ABSORPTION 

The  first  fact  to  be  gathered  relative  to  pus  absorption  is  the 
circumstances  that  favor  that  absorption.  In  many  instances,  if 
there  is  a  large  area  of  surface  uncovered  by  epithelium,  enough 
toxins  may  be  absorbed  to  produce  toxic  symptoms;  and  yet  cases 
are  constantly  appearing  in  which  a  mucous  membrane  is  bathed 
with  pus,  or  a  large  granulating  area  is  pouring  out  large  quantities 
of  pus,  with  little  or  no  constitutional  symptomatology.  On  the 
other  hand,  a  very  small  suppurative  focus,  from  which  there  is  no 
free  vent  for  the  pus,  may  produce  the  most  violent  symptoms.  The 
virulence  of  the  infection,  cceteris  paribus,  is  necessarily  one  of  the 
factors  determining  the  symptoms  present.  Second,  the  absorp- 
tive capacity  of  the  surface  or  tissue  with  which  the  pus  lies  in 
contact.  Third,  the  area  of  that  surface;  and,  fourth,  the  tension 
under  which  absorption  takes  place.  So,  when  pus  is  present  in 
the  peritoneal  cavity  it  produces  less  dangerous  symptoms  if  it 
comes  in  contact  with  the  lower  pelvic  peritoneum  rather  than  with 
the  upper.  >ince  the  diaphragmatic  portion  is  more  absorptive  than 
t  he  pelvic  portion.  Again,  if  a  portion  of  the  peritoneal  cavity  only 
be  affected,  the  greatest  care  is  demanded  in  surgical  work  not  to 
scatter  the  infection  over  a  wider  field.  A  factor  that  militates 
against  absorption  of  the  poisons  of  pus  is  the  formation  of  cicatri- 
cial  tissue  around  the  focus,  but,  unfortunately  enough,  this  is 
found  to  occur  extensively  only  after  the  lapse  of  some  weeks,  and 
• -an not  be  of  value  in  the  most  dangerous  acute  conditions.  The 
more  closely  in  touch  with  the  nerve-centers  a  Mippurative  process 
lie-  the  more  dangerous  it  is,  for  manifest  reasons.  When  a  suppu- 
rative process  affects  the  endothelium  of  the  circulatory  apparatus, 
or  when,  by  proximity  to  the  voxels,  the  pus  may  burrow  its  way 


144  PRINCIPLES   OF   SURGERY 

through  the  vessel  walls,  the  outlook  is  extremely  grave,  owing  to  a 
direct  infection  of  the  blood  and  consequent  wide  dissemination  of 
septic  emboli. 

An  individual  who  is  ill  from  the  absorption  of  poisons  from 
pyogenic  bacteria  is  said  to  be  septic. 

Symptoms  of  Pus  Absorption. — The  symptoms  of  pus  absorp- 
tion are  as  varied  as  are  the  degrees  of  toxicity  and  the  dosage  taken 
into  the  circulation  in  a  given  time.  There  may  be  a  small  quantity 
of  poison  absorbed  and  the  virulence  may  be  slight,  so  that  the 
only  symptoms  noticeable  are  a  slight  rise  of  temperature  and  mal- 
aise. This  may  continue  for  a  long  time,  and  the  cause  of  trouble 
remain  obscure.  The  classic  symptoms  of  pus  absorption  (mani- 
festly in  sufficient  quantity  to  produce  a  marked  reaction)  are 
chills,  fever,  and  sweats  of  an  irregular  type.  There  may  be  one 
chill;  it  is  usually  repeated  at  uncertain  intervals  unless  the  cause 
is  removed.  The  chill  may  be  very  slight  and  of  short  duration  or  a 
mere  chilliness,  or  it  may  be  violent,  and  last  from  twenty  to  sixty 
minutes.  The  chill  may  be  repeated  several  times  in  twenty-four 
hours,  may  come  every  day,  or  every  other  day,  with  a  deceptive 
regularity  that  misleads  the  clinician  into  a  diagnosis  of  malaria. 
There  may  be  several  chills  and  then  an  entire  cessation  of  them. 
The  fever  is  as  irregular  in  its  course  as  the  chills;  its  typic  fea- 
ture is  this  irregularity;  it  may  rise  and  fall  several  times  a  day,  run 
high  one  day  and  low  the  next,  high  in  the  morning  and  low  in  the 
afternoon.  On  the  other  hand,  it  may  at  times  be  so  regular  as  to 
cause  confusion  with  malaria  or  typhoid.  The  fever  of  pus  absorp- 
tion is  a  continued  fever  usually.  Remissions  occur  frequently; 
intermission  less  frequently,  and  then  the  temperature  goes  to  sub- 
normal. Therefore,  by  simply  looking  at  a  carefully  kept  chart 
one  will  often  be  able  to  say  that  only  a  septic  patient  could  produce 
such  a  picture.  Unfortunately,  this  is  not  always  true. 

Sweats  are  the  last  of  the  septic  trio.  They,  too,  are  variable 
in  degree.  One  case  presents  only  a  clammy  skin,  which  is  cold 
and  has  a  peculiar  unpleasant  feel,  like  the  skin  of  the  dead.  In 
another  instance  the  sweats  are  drenching  and  often  repeated. 
The  chills,  fever,  and  sweats  may  occur  in  any  relation  to  each 
other;  any  one  of  them  may  be  absent  without  affecting  the  diag- 
nosis materially,  but  the  fever  does  not  remain  absent  long  except 
in  severely  poisoned  cases;  and  the  sweating,  when  thought  to  be 
absent,  can  usually  be  discovered  by  close  observation. 

It  is  sufficient,  to  show  the  difficulty  of  diagnosis,  to  say  that, 
owing  to  irregularities  in  the  four  conditions,  typhoid,  malaria, 
tuberculosis,  and  sepsis  have  to  be  differentiated  with  utmost  care. 

Besides  the  above  symptoms,  the  presence  of  additional  corrob- 
orative symptoms  is  usually  observed.  Malaise,  headache,  ex- 


SUPPURATION  145 

hau-tion,  loss  of  appetite,  coating  of  the  tongue,  constipation,  high 
color,  and  diminished  quantity  of  urine  and  the  general  appearance 
of  t  he  patient,  whose  facies  is  pinched  and  whose  features  are  drawn 
and  contracted,  whose  countenance  is  pale,  and  with  perhaps  cy- 
auotic  lips,  and  whose  expression  is  anxious,  are  all  seen  in  the 
typic  picture  of  septic  poisoning.  Patients  who  are  absorbing 
pus  lose  weight;  in  the  severe  cases  with  incredible  rapidity,  and 
those  who  have  an  unexplainable  and  persistent  loss  of  appetite 
.should,  according  to  Musser,  always  be  investigated  thoroughly  to 
tin<l  or  to  exclude  a  suppurative  focus.  The  leukocyte  count  is  of 
very  great  value  in  acute  suppurative  processes,  but  of  little  or  no 
service  in  the  chronic. 

In  certain  cases  of  septic  intoxication  the  symptoms  assume 
the  appearance  of  a  well-developed  typhoid  condition. 

The  fact  that  pus  absorption  may  cause  only  a  slight  symptom- 
at  i  »li  >gy  does  not  excuse  failure  to  search  for  the  cause,  and,  having 
determined  that  it  is  septic,  the  exact  location  must  be  diligently 
sought  out.  First,  for  the  reason  that  immeasurable  mischief 
may  be  done  by  neglect  of  mild  pyogenic  infection;  and,  second, 
because  the  conditions  which  must  be  differentiated  from  it  may 
prove  even  more  dangerous.  They  are  malaria,  typhoid,  tubercu- 
lous of  various  structures,  and  malignant  disease,  especially  that 
affect  iim  internal  organs.  Only  by  the  most  faithful  search,  by 
physical  examination,  and  by  laboratory  methods  can  the  diag- 
no-is  be  assured. 

Suppuration  occurs  on  the  surface  of  the  body,  in  wounds  and 
sinuses,  on  the  mucous  surface,  in  mucous  and  serous  cavities 

mema),  and  in  the  tissues  (abscess). 

ABSCESS 
Definition. — An  abscess  is  an  accumulation  of  pus  circumscribed 

in  a  cavity  of  its  own  formation. 

Etiology. — The  cause  of  abscess  is  pyogenic  infection,  which 
may  have  been  deposited  by  injury  or  accident,  by  the  lymphatics, 
or  1)\  the  blood-current.  In  certain  instances  the  infection  seems 
to  have  passed  through  the  epithelial  coverings  without  previous 
injury.  The  possibility  of  bacteria  entering  through  intact  sur- 
has  been  demonstrated  by  rubbing  the  skin  of  the  forearm 
with  pure  cultures  of  Staphylococcus  aureus. 

/•'  a  run df,  Boil. — Furuncle,  or  boil,  is  a  cutaneous  abscess  due 
to  .1  circum-crilted  inflammation  of  the  corium  and  the  subcuta- 
neou>  connective  ti-sue.  They  may  be  single  or  multiple,  and 
when  multiple  they  may  be  synchronous  or  -uccessive.  The  ap- 
pearance ,,f  several  furuncles  at  approximately  the  same  time  or  in 
succe— ive  crop-  i-  termed  furunculo-i-. 
10 


146 


PRINCIPLES   OF   SURGERY 


Whitlow,  Felon. — Whitlow,  felon,  bone-felon,  panaris,  or  pana- 
ritium  is  an  abscess  formed  deep  in  the  phalanges.  It  may  be 
situated  either  in  the  deep  connective  tissue  or  subperiosteally,  the 
terms  being  more  appropriately  denned  as  a  subperiosteal  phalan- 
geal  abscess. 

Onychia,  Paronychia. — Onychia  is  an  abscess  of  the  tissues  near 
the  nail  of  the  finger.  Paronychia  is  an  abscess  in  or  near  the 
matrix  of  the  nail. 

Carbuncle. — A  carbuncle  is  an  abscess  which  results  in  a  con- 
siderable sloughing  of  the  cutaneous  and  subcutaneous  tissue. 


Fig.  19. — Carbuncle  of  nape  of  neck. 

It  is  sometimes  defined  as  a  multilocular  abscess  in  \vhich  there 
are  several  foci  of  necrosis  and  suppuration,  and  in  which  these  foci 
unite  by  necrosis  of  the  intervening  tissue.  Carbuncles  are  seen 
most  often  on  the  neck,  back,  and  buttocks. 

Pathology  of  Acute  Abscess. — The  pathologic  changes  in  the 
tissues  that  surround  an  abscess  are  very  easy  to  understand  when 
one  recalls  that  abscess  is  invariably  the  result  of  an  inflammation. 
In  the  central  portion  of  the  inflamed  mass  the  tissue  necroses,  and 
is  peptonized  and  converted  more  or  less  completely  into  pus. 


SUPPURATION  147 

( )n  the  border  between  the  abscess  cavity  and  the  inflamed  tissue 
the  process  of  repair  undertakes  to  heal  the  lesion.  So  that  one 
on  the  outside  inflammation,  next  within  this  is  a  healing 
process,  granulation  or  embryonic  tissue,  and  in  the  center  pus  and 
nrrn  >t  ic  tissue.  The  changes  occurring  in  abscess  have  been  graph- 
ically illustrated  as  follows:  From  without  inward,  (1)  a  zone  of 
hyperemia;  (2)  a  zone  of  congestion;  (3)  a  zone  of  stasis — dia- 
pedesis  and  exudation  are  abundant  in  the  latter  two;  (4)  a  zone  of 
emKryonic  or  granulation  tissue;  (5)  the  shreds  and  unseparated 
necrotic  ti--ue  lining  the  abscess  cavity;  (6)  pus.  In  furuncles 
a  core  is  present,  representing  the  unpeptonized  remains  of  the 
necrotic  mass.  This  is  attached  to  the  surrounding  connective 
ti--ue  or  separated  from  it,  according  to  the  advancement  of  the 
process.  After  complete  separation  of  the  dead  tissue  from  the 
al»cr-s  wall  the  granulation  tissue  rapidly  fills  up  the  cavity  with 
scar  tissue,  but  it  cannot  advance  far  with  the  work  until  this  pus 
has  been  given  free  exit. 

The  extent  and  behavior  of  an  abscess  depends  largely  on  the 
anatomic  limitations  of  its  site  of  formation.  In  one  instance  an 
abscess  forms,  and  can  only  extend  by  rupture  of  rigid  walls  of 
fa.-ciie  or  bone  surrounding  it,  and  the  pus  is  on  this  account  little 
likely  to  escape  from  its  primary  focus.  In  another  instance  the 
al>.-cess  formation  may  be  in  the  midst  of  a  homogeneous  but  easily 
dr-tructible  tissue,  and  the  action  of  the  infection  may  gradually 
<  le.-t  1 1  }\  more  and  more  of  the  tissue.  Here  the  natural  limitations 
do  not  assist  the  pathologic  in  preventing  extension.  In  still 
another  case  the  abscess  forms  in  a  region  where  escape  is  favored 
1 1\  the  relative  position  of  the  planes  of  fasciae  or  by  openings  for 
Mood-vessels,  nerves,  and  tendons,  and  any  marked  accumulation 
of  pus  is  likely  to  find  its  way  from  the  primary  focus  to  a  near  or 
remote  field.  Gravity  influences  the  direction  of  escape,  other 
thing-  lieing  equal.  The  po-.-i!>ilit y  of  such  an  accident,  and  the 
anatomic  fields  where  it  is  favored,  must  be  borne  in  mind,  for, 
while  in  its  original  site  the  abscess  may  be  accessible  and  easily 
treated,  its  new  lodging  place  may  present  insurmountable  diffi- 
cult;. 

Types  of  Abscess. — Below  are  given  a  number  of  terms  applied 
to  al»sccs>es.  \Yhile  all  of  them  are  either  acute  or  chronic,  their 
significance  i-  of  -uHicient  importance  to  be  given  in  detail.  Such 
term-  a-  an-  >•  •lf-dcfining  or  refer  to  anatomic  location  are  omitted, 
miles-  they  rei|iiiiv  -ome  special  comment. 

Alrcnlnr  <il IMS*,  gum-boil,  or  parulis,  i-  an  al>-cessof  the  gum, 
iatcd  with  an  infection  in.  around,  or  predisposed  to  by  the 
teeth.  The  pus  forms  at  the  root  of  the  tooth,  usually  at  the 
apc\.  following  a  periostitis,  and  by  absorption  of  the  bone  gains 


148 


PRINCIPLES   OF   SURGERY 


escape  under  the  mucoperiosteum.  The  causative  agency  of  the 
tooth  and  the  sinus  through  the  alveolus,  allowing  escape  of  the 
pus,  should  always  be  remembered  in  treatment. 

Amebic  abscess,  or  tropical  abscess,  is  due  to  invasion  of  the 
liver,  through  the  portal  vein  according  to  some,  while  others  claim 
the  route  is  through  the  bile-channels,  by  the  ameba  dysenterise, 
and  secondary  to  the  lesions  produced  by  this  protozoon  in  the 
lower  alimentary  tract.  The  abscess  may  be  single  or  multiple, 
and  is,  of  course,  more  amenable  to  treatment  when  single.  It  is 
usually  found  in  the  right  lobe  of  the  liver,  and  may  be  recognized 


Fig.  20. — Multiple  abscess  of  liver.     (X  about  f .) 


as  hepatic  abscess  by  the  appearance  of  liver-cells  in  the  pus; 
this  is  of  especial  value  when  rupture  into  a  bronchus  has  occurred. 
Amebic  abscess,  often  of  enormous  proportions,  may  contain  the 
causative  ameba,  often  associated  with  pyogenic  bacteria,  but  at 
times  shows  no  causative  organism,  and  has  thus  gained  in  these 
cases  the  manifestly  incorrect  name  of  idiopathic  abscess. 
Strangely  enough,  tropical  abscess  occurs  with  greater  frequency 
in  the  milder  cases  of  amebic  dysentery. 

Atheromatous  abscess,  chiefly  of  pathologic  interest,  and  not 
belonging  in  the  present  group  except  by  virtue  of  its  name,  is  a 
collection  of  cholesterin  with  other  material  under  the  intima  of 


SUPPURATION  149 

arterie-  in  chronic  endarteritis.     By  rupture  into  the  lumen  of  the 

-.  -1-  it  causes  atheromatous  ulcer. 

Bezold's  abscess,  or  disease,  is  the  condition  resulting  from 
perforation  of  suppurative  mastoiditis  into  the  tissues  of  the  neck, 
:ind  causing  suppuration,  which  infiltrates  the  loose  tissues  of  the 
neck  and  produces  a  brawny  induration. 

Brodie's  abscess  is  usually  tubercular.  It  occurs  usually  in  the 
head  of  the  tibia,  occasionally  in  other  bones. 

Canalicular  abscess  is  an  abscess  of  the  mammary  gland  which 
has  ruptured  into  a  lactiferous  duct,  and  whose  contents  thus  escape 
at  the  nipple  and  may  cause  serious  illness  of  the  infant  if  allowed 
to  nurse  the  diseased  breast. 

Caseous  abscess  contains  a  cheesy  matter,  and  is  usually  due  to 
tubercular  infection.  It  is  a  subdivision  under  chronic  or  cold  ab- 
scess. The  caseous  material  is  mixed  with  the  so-called  tubercular 
pus.  and  represents  that  part  of  the  tuberculous  product  which  has 
not  liquefied.  In  cold  abscesses  the  presence  of  caseous  material 
interferes  with  aspiration. 

Cold,  or  chronic,  abscess  is  of  slow  formation  compared  with 
acute  abscess;  it  results  from  chronic  or  subacute  inflammations, 
usually  tubercular,  and  the  name  contra  distinguishes  it  from  acute 
< >r  hi »t  al  >sn as.  It  shows  little  or  no  local  rise  of  temperature  in  the 
surrounding  structures. 

Congestive  abscess  is  one  in  which  the  pus  cannot  accumulate  at 
the  site  of  formation  owing  to  resistance  of  surrounding  structures, 
and  is  hence  forced  to  escape  and  accumulate  at  some  convenient 
point.  It  i>  xiinet lines  classed  as  synonymous  with  wandering  or 
hypostatic  abscess.  It  is  exceedingly  necessary  to  know  that  such 
abscesses  do  not  form  in  situ,  as  treatment  fails  then  to  reach  the 
real  source  of  disease. 

Conxlitutinnal  abscess  forms  as  the  result  of  general  or  constitu- 
tional infection  and  is  insignificant  in  comparison  with  the  favor- 
ing pathology.  Pyemic  abscesses  belong  to  this  class  and  tuber- 
cular abscesses  do  at  times. 

Dry  abscess  is  one  in  which  the  fluid  contents  are  absorbed 
and  the  residue  is  more  or  less  completely  removed,  but  no  rupture 
has  occurred  and  no  incision  has  been  made.  It  is  an  abscess  that 
dries  up. 

Dnbois'  abscess  is  a  supposed  abscess  of  the  thymus  gland  hi 
syphilitic  children,  and  was  formerly  claimed  to  be  pathognomonic 
of  that  di-ea-e.  It  is  ueit her  pat h< >miomonic  nor  is  it  abscess,  but 
i-  due  to  po-tmortem  .-oftenini:  or  to  cy>t  formation,  the  contents 
Keing  puruloid.  "They  have  nothing  to  do  with  syphilis"  (Kauf- 
niann  . 

abscess,  secondary  to  embolism,  forms  in  or  around  an 


150  PRINCIPLES   OF   SURGERY 

embolus,  and  is  due  to  infection  carried  in  the  embolus  or  predis- 
posed to  by  the  disturbance  of  nutrition  caused  by  lodgment  of 
the  embolus. 

Encysted  abscess  occurs  hi  serous  cavities,  and  occupies  only 
a  portion  of  the  cavity,  being  confined  by  adhesion  of  serous  sur- 
faces by  plastic  exudate,  which  may  organize.  The  abdominal 
and  pleural  cavities  are  affected. 

Fecal,  stercoraceous,  or  stercoral  abscess  occurs  in  connection 
with  the  colon,  sigmoid,  or  rectum,  and  contains  fecal  matter. 

Ischiorectal  abscess  forms  in  the  ischiorectal  fossa,  and  is  of 
especial  interest  because  it  is  the  cause  of  fistula  in  ano  consequent 
upon  rupture  or  incision,  and  because,  in  the  majority  of  cases, 
it  is  of  tuberculous  origin.  Both  of  these  facts  demand  considera- 
tion in  the  treatment  and  prognosis  of  ischiorectal  abscess.  When 
allowed  to  rupture  there  may  be  an  external  or  an  internal  opening 
or  both.  At  times  both  fossae  may  be  occupied  by  the  abscess  and 
result  in  a  horseshoe  fistula. 

Lacunar  abscess  is  one  forming  in  the  lacunae  of  the  urethra. 
They  are  usually  of  gonorrheal  origin. 

Marginal  abscess  occurs  at  or  near  the  margin  of  the  anus, 
either  on  the  skin  or  mucous  membrane.  They  originate  from 
infection  admitted  through  the  solitary  glands  or  Lieberkiihn's 
follicles,  hair-follicles,  and  sebaceous  glands.  They  may  be 
small,  and  have  almost  the  appearance  of  acne,  or,  by  infiltration, 
may  affect  a  considerable  superficial  area.  They  do  not  extend 
deeply  enough  to  affect  the  ischiorectal  fossa. 

Mastoid  abscess,  which  should  properly  be  called  an  empyema, 
is  an  accumulation  of  pus  in  the  cells  of  the  mastoid,  and  is  second- 
ary to  infection  of  the  middle  ear.  It  is  frequently  associated  with  or 
followed  by  serious  intracranial  complications,  as  thrombosis  of  the 
lateral  sinus,  cerebral  abscess,  edema  of  the  brain,  and  meningitis. 

Metastatic,  secondary  or  pyemic,  abscess  is  always  secondary 
to  some  more  or  less  remote  infection  which  gains  access  to  the 
circulation,  usually  hi  the  form  of  an  infected  embolus,  which 
produces  the  secondary  abscess  at  its  point  of  lodgment.  The 
most  common  conditions  showing  metastatic  abscesses  are  pye- 
mia,  ulcerative  endocarditis,  and  septic  thrombosis.  In  the  true 
sense  of  the  term  metastasis  embraces  also  those  secondary  ab- 
scesses whose  infection  is  transmitted  through  the  lymph-channels, 
although  it  is  usually  accepted  to  be  transmitted  by  the  blood. 

Miliary  abscesses  are  secondary  or  metastatic,  multiple,  and 
of  small  size,  like  millet  seed.  They  are  not  simply  multiple,  but 
usually  numberless,  so  that  large  viscera,  like  the  liver  and  the 
spleen,  will  show  them  throughout  their  volume.  Their  presence 
indicates  a  hopeless  prognosis. 


SUPPURATION  151 

Milk  abscess  occurs  in  the  female  breast,  and  is  especially 
frequent  in  nursing  women. 

Mi i ml  abscess  is  found  in  the  abdominal  wall,  between  perito- 
neum within  and  skin  without.  It  is  of  especial  interest,  because 
of  the  necessity  for  determining  whether  it  is  an  intra-  or  extra- 
peritoneal  abscess.  Mural  abscess  may  be  secondary  to  lapa- 
rotomy,  especially  when  an  infected  structure,  like  a  gangrenous 
or  -nppurative  appendix,  is  excised.  They  are  often  observed 
under  these  conditions  with  no  sign  of  coincident  peritoneal  infec- 
tion. 

Ossifluent  abscess  forms  as  a  result  of  bone  infection.  The 
al»cess  may  be  contained  within  the  bone  and  lie  under  the 
peril  Kteum  or  escape  through  cloacae  in  the  bone,  then  through 
the  periosteum,  and  be  found  in  the  soft  tissues,  often  at  sites 
deceptively  remote  from  the  primary  lesion.  The  primary  focus 


ullary  canal  of  ulna. 

may  l>e  discovered  by  opening  the  abscess  and  following  the  sinus 
or  by  skiagraphs,  either  with  or  without  previous  injection  of 
liiHuuth  paste;  but  the  skiagrams  are  more  definite  and  reliable 
if  the  paste  is  used. 

Perforating  abscess  is  one  that  perforates  its  limiting  wall.  A 
hepatic  abscess  may  perforate  into  the  greater  or  lesser  peritoneal 
cavity,  or  a  pulmonary  abscess  into  the  pleural  cavity. 

r>  rini'i>lii -ic,  or  perinephritic,  abscess  forms  in  the  tissues  sur- 
rounding thekidney,  especially  in  the  poorly  vitalized  perirenal  fat. 
The  infection  may  be  primary  in  the  perirenal  tissue  or  may,  as 
some  think,  l.e  due  to  infection  Krou.uht  to  the  kidneys  in  their 
effort  at  elimination  of  bacteria,  and  especially  via  the  lymphatics 
frnin  the  surrounding  tissues.  In  t  he  latter  instance  it  is  secondary' 
to  an  infection  situated  elsewhere  in  the  body.  Perinephric 
ali-cesses  may  attain  enonnou-  -i/e.  and  are  either  unilateral  or 
bilateral. 


152  PRINCIPLES   OF   SURGERY 

Peritonsillar  abscess,  or  quinsy,  is  an  abscess  affecting  the  tonsil 
and  the  peritonsillar  tissue.  This  abscess  may  cause  marked  de- 
struction of  tissue.  It  occurs  in  individuals  of  plethoric  habit,  and 
is  rarely  observed  in  the  very  young  or  very  old.  The  infection 
gains  entrance  through  the  mucous  membrane  of  the  fauces  or 
the  tonsil,  through  the  tonsillar  crypts.  By  delay  in  treatment  the 
abscess  may  burrow  into  the  retropharyngeal  space  and  produce  a 
retropharyngeal  abscess,  or  by  extension  into  the  thorax  produce  a 
suppurative  mediastinitis  or  pleurisy;  edema  of  the  larynx  is  some- 
times a  complication.  In  cases  of  so-called  cryptogenetic  pyemia 
and  other  suppurative  conditions  of  obscure  origin  the  tonsils 
should  be  closely  examined. 

Postpharyngeal,  or  retropharyngeal,  abscess  is  situated  behind 
the  posterior  pharyngeal  wall.  It  is  usually  a  secondary  or  a 
wandering  abscess,  due  to  extension  of  infection  from  some  neigh- 
boring inflammatory  process,  or  rather  to  the  escape  of  pus  from 
some  adjacent  suppurative  focus  into  the  loose  postpharyngeal 
connective  tissue.  The  source  of  retropharyngeal  abscess  is 
usually  the  bones  of  the  cranial  base,  the  upper  cervical  vertebrae, 
infections  about  the  tonsils  and  fauces,  and  of  the  deeper  cervical 
lymph-nodes.  They  may  be  acute  or  chronic,  and  in  either  in- 
stance are  of  intense  concern  to  the  surgeon  on  account  of  their 
danger,  whether  treated  or  left  alone.  A  large  retropharyngeal 
abscess  may  interfere  with  swallowing  or  respiration,  especially  if 
it  be  acute  and  considerable  edema  be  associated  with  it.  There 
is  the  constant  danger  of  escape  downward  along  the  loose  planes 
of  connective  tissue  into  the  mediastinum  or  of  rupture  into  the 
pleural  cavity.  It  may  rupture  into  the  pharynx  and  cause  death 
by  strangulation  during  exertion,  as  when  an  anesthetic  is  being 
administered,  or  during  sleep;  or,  if  strangulation  be  escaped, 
septic  aspiration  pneumonia  may  follow  quickly.  If  these  acci- 
dents are  avoided,  and  if  the  abscess  is  opened  or  ruptures  into 
the  pharynx,  the  constant  deglutition  of  the  bacteria  ejected  may 
cause  grave  complications,  far  graver  often  than  the  primary 
condition,  or  a  secondary  infection  may  be  admitted  through  the 
opening,  and  render  a  previously  favorable  condition  hopeless. 

Psoas,  or  lumbar,  abscess,  usually  tubercular,  is  a  wandering 
abscess  whose  pus  forms  in  a  tuberculous  focus  in  the  lumbar  or 
lower  thoracic  vertebrae  and  escapes  into  the  sheath  of  the  psoas 
muscle,  under  which  it  gravitates  downward,  until  it  meets  with 
sufficient  resistance  near  the  level  of  the  pubic  spine  or  Poupart's 
ligament  to  check  it.  The  bulging  of  the  abscess  may  lie  above 
Poupart's  ligament,  when  it  may  be  confused  with  intraperitoneal 
conditions,  or  below  the  ligament,  and  be  confused  with  femoral 
hernia.  The  abscess  usually  points  in  Scarpa's  triangle  external  to 


SUPPURATION  153 

the  femoral  vessels.  Occasionally  the  pus  burrows  along  the  course 
of  the  circumflex  vessels  and  appears  behind  the  trochanter  major, 
or  it  may  rupture  into  the  bursa  lying  between  the  psoas  and  the 
capsule  of  the  hip-joint,  and  thus  pour  its  contents  into  the  joint 
cavity.  In  addition  to  the  above,  the  pus  may  burrow  through 
the  psoas  sheath  into  the  iliac  fossa,  into  the  pelvis,  beneath  the 
pelvic  fascia,  through  the  great  sacrosciatic  foramen,  and  appear 
in  t  he  tfluteal  region,  or  through  the  obturator  fascia  into  the  iscbio- 
rectal  space,  and  appear  as  an  ischiorectal  abscess.  Rarely,  the 
pus  from  psoas  abscess  escapes  into  the  thigh  below  the  hip  and 
may  reach  as  low  as  the  knee. 

Hfsidual  abscess,  or  Paget's  abscess,  is  one  which  forms  at  the 
site  of  an  old  infection  or  abscess,  whose  incompletely  destroyed 
residue  remains  indefinitely  encysted  in  the  tissues,  and  produces 
no  disturbance  until  the  bacteria  are  called  into  activity  by  some 
accident,  such  as  an  injury,  or  until  some  infection  may  be  lodged 
at  this  focus  and  give  a  new  impetus  to  the  dormant  infection. 
The  bacteria  usually  found  in  these  cases  are  tubercle  bacilli,  and 
so  a  serious  complication  may  grow  out  of  an  insignificant  trauma. 
The  possibility  of  such  an  accident  must  be  borne  in  mind  in  all 
where  surgical  interference  is  recommended  subsequent  to 
the  apparent  healing  of  a  tubercular  lesion. 

Shirt-stud  abscess  has  two  cavities,  a  superficial  and  a  deeper  one, 
connected  with  each  other  by  a  communicating  sinus.  • 

Stitch,  or  stitch-hole,  abscess  forms  around  or  in  contact  with 
snturc>s;  usually  sutures  which  have  been  introduced  through  the 
skin.  The  sutures  carry  the  infection  from  the  surface  and  outer 
layers  of  the  skin;  hence,  some  surgeons  recommend  the  introduc- 
tion of  all  sutures  toward  the  epithelial  surface,  never  from  it;  or 
the  infection  may  be  brought  into  the  skin  and  subcutaneous  fascia 
l>y  capillarity  of  the  suture.  Stitch  abscesses  occur  with  too  great 
frequenry.  usually  in  cases  where  no  deeper  infection  is  manifest. 
The  infection  of  stitch  abscess  is  most  frequently  Staphylococcus 
epidermidis  allms,  which  causes,  as  a  rule,  a  mild  infection  with 
little  tendency  to  spread.  Of  course  other  infections  are  found, 
usually  caused  by  bacteria  which  habitually  attach  to  the  body 
surface  or  live  in  the  glands  and  follicles.  The  infection  may  also 
l»e  attributed  to  soiling  the  tissues  during  the  removal  of  pathologic 
t  i— ue  t  hnmnh  the  wound.  Stitch  abscess  is  less  likely  to  form,  and, 
in  ca>e  it  should  form,  likely  to  be  of  smaller  size,  if  the  sutures  are 
n«>t  allowed  to  make  undue  pressure  on  the  tissue  within  their 
grasp.  Krmoval  of  the  suture  concerned  and  gentle  cleansing  is 

UMlally  Mlflicieilt    to  relieve  them. 

Suhdiii/thnu/rnatic,  or  Kub/i/m  nic,  ttlwt  x*  is  usually  secondary  to 
an  infection  situated  in  the  upper  abdomen  and  to  appendicitis. 


154  PRINCIPLES   OF   SURGERY 

It  is  frequently  tympanitic,  and  occasionally  relieves  itself  by 
burrowing  through  the  diaphragm,  across  parietal  and  visceral 
pleura  adherent  to  each  other  at  the  base  of  the  lung,  and  into  the 
lung  tissue,  whence  it  escapes  through  a  bronchus.  If  the  pleurae 
are  not  adherent  the  perforation  of  the  diaphragm  results  in  pyo- 
thorax  or  pyopneumothorax. 

Thecal  abscess  is  an  accumulation  of  pus  in  a  tendon  sheath. 

Tympanitic  abscess  is  one  which  contains  both  pus  and  gas. 
This  gas  may  be  produced  by  the  causative  infection,  or  it  may 
be  due  to  the  entrance  of  gas  into  the  tissues  through  a  wound  which 
produces  a  communication,  for  example,  with  the  lung  or  a  bron- 
chial tube. 

Urinous  abscess  contains  pus  and  urine  which  has  extravasated 
into  the  tissues  through  lesions  which  communicate  with  the 


Fig.  22. — Ruptured  uriniferous  abscess  resulting  from  strictured  urethra. 

urinary  apparatus.  They  are  seen  usually  in  males,  and  follow 
strictures  of  the  urethra  in  the  majority  of  cases. 

Local  Signs  and  Symptoms. — The  local  signs  and  symptoms  of 
acute  abscess  are:  (a)  a  history  of  an  acute  inflammation;  (6)  fluc- 
tuation; (c)  softening;  (d)  pointing;  (e)  edema  of  surrounding  soft 
tissues;  (/)  pus  on  aspiration. 

(a)  The  history  of  inflammation  embraces  all  the  local  and  con- 
stitutional signs  and  symptoms;  often  such  a  history  cannot  be 
elicited.  The  duration  of  the  inflammatory  process  prior  to  sup- 
puration may  vary  from  a  few  hours,  as  in  fulminating  cases,  to 
several  days. 


SUPPURATION  155 

(6)  Fluctuation  does  not  signify  the  presence  of  pus,  but  simply 
the  presence  of  fluid,  the  nature  of  which  must  be  determined  by 
other  evidence.  By  fluctuation  one  means  the  wave  sent  from  one 
>ide  of  a  cavity  filled  with  fluid  to  the  other.  To  determine  its 
presence  one  hand  is  placed  on  one  side,  and  the  opposite  side  is 
tapped  lightly  and  quickly  by  the  other  hand.  The  wave  is  pro- 
duced by  the  latter  and  felt  by  the  former.  If  the  part  be  loose 
and  soft,  as  in  fat  abdomens,  more  satisfactory  examination  can 
be  done  by  having  an  assistant  place  the  inner  side  of  his  hand 
against  the  surface  between  the  palpating  and  the  percussing  hand, 
with  the  plane  of  the  assistant's  hand  at  a  right  angle  to  the  line  of 
transmission.  The  assistant  must  make  firm  pressure,  but  not 
enough  to  collapse  the  underlying  activity.  The  assistant's  hand 
thus  interrupts  the  deceptive  wave  transmitted  by  the  overlying 
soft  tissues.  In  attempting  to  elicit  fluctuation  in  the  arm  or 
thigh,  especially  in  case  of  stout  individuals  or  those  whose  muscles 
are  well  developed,  it  is  necessary  to  place  the  palpating  hand 
above  or  below  the  percussing  hand,  in  the  long  axis,  as  an  apparent 
fluctuation  can  be  obtained  normally  by  transverse  palpation. 

In  many  cases  it  is  necessary  to  determine  whether  fluctuation 
is  present  or  not,  and  yet  impossible  to  place  both  hands  in  the 
position  above  recommended.  This  is  manifestly  true  in  rectal, 
vaginal,  and  oral  examinations.  By  a  little  practice  one  may  be- 
cnine  able  to  recognize  fluctuation  or,  if  not  that,  the  presence  of 
fluid  by  using  a  single  hand  or  a  single  finger.  It  is  difficult  to 
ibe  just  what  happens,  but  we  may  say  that  there  is  a  tense- 
md  an  elasticity  which  reminds  one  of  the  feeling  of  a  rubber 
l>ag  filled  with  water;  or  the  surface  may  be  struck  with  the  finger 
which  holds  in  touch  with  the  mass,  and  catches  the  wave  on  its 
return  from  the  opposite  side. 

Pseudofluctuation  is  fluctuation  obtained  in  bodies  not  filled 
with  fluid,  or,  better,  not  containing  a  cavity  filled  with  fluid. 
Reference  has  already  been  made  to  the  confusion  arising  from 
pKiidofhictuation  of  the  abdominal  walls  and  of  the  extremities 
of  stout  individuals.  It  is  found  in  certain  tumors,  especially 
lipomata  when  of  fair  size,  and  in  the  very  soft  or  very  vascular 
malignant  tumors.  It  is  also -mi  in  cases  of  extensive  edema,  and 
may  appear  as  an  unquestionable  fluctuation  here.  It  may  be 
impo»iHe,  uinler  certain  circumstances,  to  say  whether  fluctua- 
tion or  peeudofluct nation  is  present. 

(c)  Sitfh  ninti.  There  is  a  certain  amount  of  induration  in  the 
ordinary  inflamed  >tructure.  When  a  portion  of  this  indurated 
infiltrated  ti->ue  i-,  converted  into  pus.  -oftening  is  observed,  and 
if  the  pus  cavity  is  palpable  the  softening  will  l>e  found  coextensive 
with  the  pu>  formation.  The  -oftening  is  all  the  more  apparent 


156  PRINCIPLES   OF   SURGERY 

when  contrasted  with  the  indurated,  inflamed  boundaries,  but  is 
less  easily  recognized  when  this  boundary  is  wanting,  as  in  subacute 
and  chronic  abscesses.  The  softness  of  an  abscess  large  enough  to 
palpate  satisfactorily  is  greater  than  that  of  the  softest  normal  tis- 
sues. 

(d)  Pointing. — The  tendency  of  an  abscess  is  to  relieve  itself 
by  opening  upon  some  surface  of  the  body;  the  direction  taken  is 
along  the  lines  of  least  resistance.  As  the  peptonizing  action  of 
the  bacteria  continues,  from  a  beginning  central  zone  toward  the 
periphery,  the  pus  gradually  approaches  some  surface,  cutaneous, 
mucous,  or  serous,  and  when  this  surface  is  approached  the  resist- 
ance of  the  tissues  to  the  pressure  of  the  pus  is  reduced  and  the 


Fig.  23.— Infected  hand. 

surface  bulges  at  this  point.  This  bulging  is  known  as  pointing. 
The  place  of  pointing  is  that  at  which  rupture  of  the  abscess  will 
occur  if  allowed  to  pursue  its  own  course,  although  it  is  by  no  means 
always  at  the  most  advantageous  place  for  emptying  and  thus  heal- 
ing the  abscess.  The  place  of  pointing  is  that  of  greatest  softening, 
that  at  which  pus  can  be  most  easily  reached  by  the  knife  or  the 
aspirating  needle. 

(e)  Edema. — Edema  may  be  seen  in  many  non-suppurative 
inflammations,  especially  in  regions  where  the  connective  tissue  is 
loose,  as  in  the  face  and  the  external  genitals.  But  in  case  of  acute 
abscess  edema  is  the  rule,  and  is  frequently  of  paramount  import- 
ance as  a  diagnostic  sign  when  other  symptoms  and  signs  are  vague 


SUPPURATION  157 

or  wanting.  The  edema  may  be  coextensive  with  the  inflamed 
area,  but  not  infrequently  extends  widely  into  surrounding'healthy 
ti— ue.  So  in  deep  suppurative  processes  its  presence  is  of  especial 
value;  still  its  absence  cannot  be  accepted  to  signify  that  an  ab- 
is  not  present.  In  suppuration  of  the  mastoid,  so-called  mas- 
toi<l  abscess,  edema  may  appear  over  the  mastoid  region,  in  abscess 
of  the  liver  over  the  lower  part  of  the  right  thorax,  and  in  inflam- 
mation of  the  bones  or  joints,  if  suppuration  is  present,  more  or 
dema  will  show. 

(/)  Pus  on  Aspiration. — The  absolute  proof  of  abscess  is  estab- 
lished when  an  aspirating  needle  can  be  introduced  and  pus  drawn 
from  the  cavity.  It  is  not  a  necessary  procedure  in  most  instances, 
and  in  many,  where  it  is  apparently  necessary,  it  is  positively 
contra-indicated.  The  centra-indication  is  found  in  abscess  of  a 
MX  us,  as  a  lung  or  the  liver,  where,  in  order  to  aspirate,  the  needle 
must  be  passed  through  a  serous  cavity  to  reach  the  diseased  organ. 
When  this  is  done  and  the  needle  withdrawn,  its  infected  surface 
cannot  fail  to  soil  the  peritoneum  or  the  pleura,  and  at  the  same 
time  leave  a  communicating  tract  between  the  serous  and  abscess 
cavity,  which,  however  minute,  favors  to  some  extent  the  escape 
of  pus.  If  it  is  considered  necessary  to  do  aspiration  under  such 
circumstances,  it  is  permissible  only  with  the  understanding  that 
if  pus  is  found  an  operation  will  be  undertaken  before  withdrawal 
of  the  needle.  Now  and  then  failure  to  find  pus  on  aspiration  is 
due  to  the  passage  of  the  needle  completely  through  the  abscess 
cavity.  Hence,  it  is  better  to  maintain  suction  during  withdrawal 
of  the  needle ,  so  that  the  possibility  of  such  an  error  may  be  eliminated. 

The  constitutional  symptoms  of  abscess  are  those  of  pus  ab- 
sorption,  already  discussed  at  some  length.  They  may  be  so  mild 
a-  to  i  M  ape  observation,  or  intense,  even  out  of  all  proportion  to 
the  local  condition.  When  the  abscess  is  drained  thoroughly  the 
constitutional  symptoms  subside  rapidly,  and  return  only  when 
real-cumulation  of  the  pus  is  permitted,  when  a  new  abscess  devel- 
op-, or  when  some  septic  complication  arises. 

Diagnosis  of  Abscess. — There  is  no  difficulty  of  diagnosis  hi 
ca-e  of  -uperficial  abscess,  as  a  rule.  If  the  skin  is  not  involved, 
however,  in  the  inflammatory  process,  or  if  the  abscess  is  situated 
deeply  among  the  muscles  of  the  hip,  in  bone,  in  the  cranial  cavity, 
or  in  the  thoracic  or  abdominal  cavity,  the  greatest  and  most 
in>uperal»le  obstacles  may  thrust  them.-elves  in  the  way.  Under 
such  circum-tance-  no  Single  sign  may  be  of  diagnostic  value,  and 
many  of  the  -ign>  and  symptoms  may  be  absent  or  indifferent,  or 
not  demonstrable  for  want  of  apparatu-  and  -killed  assistance. 
So  one  must  create  for  <>m-'-  -elf  as  much  as  po— ihle  a  picture  of 
•epos,  of  the  patient  who  i>  al>M>rl>ing  the  toxins  of  pus,  and  apply 


158  PRINCIPLES    OF   SURGERY 

it  in  every  instance,  constantly  cognizant  of  the  fact  that  great 
and  delusive  variations  are  to  be  expected.  Not  only  so ;  on  the 
other  hand,  all  other  adequate  explanations  of  the  symptomatology 
must  be  excluded. 

There  are  several  lesions  and  combinations  of  lesions  which 
•  must  be  excluded  in  making  a  differential  diagnosis  of  acute  abscess. 
Among  these  one  of  the  most  treacherous  is  the  presence  of  a 
tumor  or  a  cyst,  of  itself  incapable  of  producing  a  rise  of  tempera- 
ture, and  whose  existence  is  unknown  to  its  host,  complicated  with 
the  development  of  a  febrile  condition,  capable  of  being  considered 
septic.  A  still  worse  combination  is  found  when  such  a  tumor, 
especially  if  a  cyst  or  a  very  soft  solid  tumor,  becomes  infected 
and  develops  all  the  local  and  constitutional  signs  appertaining 
thereto.  The  history  would  suffice  if  it  could  be  obtained,  but 
could  not  be  of  value  further  than  to  show  that  the  mass  antedated 
the  symptoms;  it  could  not  exclude  the  possibility  of  an  associate 
suppuration.  In  tumors,  gummata,  and  cysts  the  definite  outlines 
usually  found  are  very  unlike  the  more  or  less  vague  outlines  of 
abscess.  In  those  cases  where  carcinoma  or  sarcoma  appears  and 
produces  febrile  symptoms  of  low  degree,  the  long  continuance  of 
the  same  case  and  the  slow  development  of  symptoms  argues 
against  acute  abscess,  but  the  accidents  which  befall  hi  the  course 
of  these  tumors  may  obscure  the  picture  completely.  One  cannot 
forget  that  malignant  tumors  may  develop  rarely  almost  with  the 
incredible  rapidity  of  acute  abscess.  The  differentiation  of  these 
conditions  is  found  most  difficult  hi  the  chest  and  upper  abdomen. 

Exclusion  of  aneurysm  may  present  difficulties  in  inaccessible 
regions,  where  the  centrifugal  expansion  of  the  aneurysm  cannot 
with  certainty  be  distinguished  from  the  lifting  of  an  abscess 
lying  over  a  large  vessel.  When  a  mass  of  any  kind  lies  over  the 
course  of  an  important  blood-vessel,  the  most  positive  evidence  of 
its  nature  must  be  produced  prior  to  attacking  it. 

When  a  secondary  or  residual  abscess  develops  hi  a  mass  of 
tissues  bound  together  by  adhesions  its  presence  will  often  be  dis- 
covered by  awaiting  the  development  of  positive  signs. 

Abscess  must  be  distinguished  from  inflamed  cysts  in  or  near 
the  skin,  as  well  as  from  those  situated  within  the  cavities  of  the 
body,  for  the  very  simple  reason  that  the  cyst  will  recur  frequently 
when  treated  as  abscess.  The  existence  of  the  mass  prior  to  the 
inflammation,  the  usually  definite  outlines,  the  location,  the  pres- 
ence of  a  comedo  if  the  cyst  is  sebaceous,  the  appearance  of  the 
contents  when  aspiration  or  excision  is  made,  showing  admixture 
of  the  cystic  contents,  and  after  incision  the  presence  of  a  smooth 
limiting  wall,  argue  for  cyst  and  against  abscess. 

Complications  and  Sequelae  of  Abscess. — Naturally  the  same 


SUPPURATION  159 

complications  and  sequelae  may  be  found  with  abscess  as  with  in- 
flammation. They  are  infection  of  lymph-nodes  of  the  nearest 
proximal  group,  lymphangitis,  ankyloses,  constrictions,  and  ob- 
structions which  follow  them,  or  the  immobilization  of  important 
( >rgans,  as  lungs  and  heart.  Thrombosis  may  occur,  and  does  occur 
with  great  frequency  when  the  abscess  is  in  close  proximity  to  a 
vein,  illustrated  best  by  thrombosis  of  the  lateral  sinus  hi  abscess 
of  the  mastoid.  Following  thrombosis,  embolism  may  come,  re- 
sulting fatally  without  a  second's  warning,  or,  if  the  embolus  lodges 
at  a  less  vital  point,  infarction,  secondary  abscess,  septicemia  or 
pyemiu  with  meta>ta>i-  may  develop. 

Prognosis  of  Abscess. — The  prognosis  of  abscess  depends  on 
th<  same  factors  as  that  of  inflammation  as  far  as  they  go,  namely, 
the  virulence  of  the  causative  bacteria,  extent,  accessibility,  and  the 
importance  of  the  structure  affected.  Furthermore,  it  depends 
upon  th»'  degree  of  development  or  the  amount  of  tissue  destroyed; 
thi-  not  infrequently  causes  death  after  the  abscess  is  cured  and 
all  infection  removed;  upon  what  cavities  and  organs  are  affected 
by  its  burrowing  or  rupture,  and  upon  the  pranks  played  by  emboli 
and  adhesions.  The  accessibility  of  abscess  to  treatment  is  of 
especial  importance,  for  in  many  regions  the  accomplishment  of  safe 
and  easy  drainage  offers  insurmountable  difficulties. 

Treatment  of  Abscess. — The  treatment  of  abscess  may  be 
divided  into  abortive  treatment,  operative  treatment,  and  consti- 
tutional treatment. 

Abortive  Treatment. — When  superficial  inflammatory  processes 
•  •n  early  enough — i.  e.,  before  pus  has  formed,  or  after  it  has 
formed  in  a  very  restricted  area — abortive  treatment  may  be  em- 
ployed with  a  fair  degree  of  success.  There  are  two  antiseptics 
employed  for  this  purpose:  one  is  pure  carbolic  acid,  a  minim  or 
two  of  which  is  injected  into  the  center  of  the  abscess  with  a  small 
hypodermic  needle.  The  objection  to  carbolic  acid  is  that 
occ:i-ionally  it  surprises  one  by  producing  gangrene,  and  that  if 
much  of  it  should  be  used  and  be  absorbed  it  will  cause  a  serious 
nephritic  The  other  safer  solution  is  glycerin  containing  2  per 
cent,  of  formalin;  of  this  mixture  5  to  10  drops  or  more,  if  the  case 
demand-  it,  may  be  injected.  The  abscess  rapidly  changes  its 
appearance  and  the  symptoms  subside,  the  necrotic  material  being 
gradually  absorbed. 

<)IH  mtive  Treatment. — The  treatment  of  abscess  as  such  may 
be  >ummed  up  in  a  very  brief  sentence — open,  clean  out,  and  drain. 

If  left  to  itself  to  rupture,  the  opening  will  be  inadequate  in 
mo<l  in.-tances,  is  very  likely  to  bo  situated  at  a  point  di-advanta- 
geous  for  drainage,  especially  if  the  abscess  is  deep  or  large,  and  en- 
tails  greater  suffering  on  the  patient  by  delay  and  greater  danger 


160 


PRINCIPLES   OF   SURGERY 


of  complications.  Hence,  when  acute  abscess  is  diagnosed,  the 
treatment  should  be  done  at  the  earliest  possible  moment  The 
size  of  the  opening  .should  be  determined  by  the  amount  of  pus, 
the  possible  duration  of  drainage,  and  the  location  of  the  abscess. 
The  tegumentary  coverings  heal  more  rapidly  than  the  abscess 
cavity,  so  provision  must  be  made  against  too  early  closure  of  the 
incision  by  making  it  large  enough  in  the  beginning.  If  a  drainage- 
tube  is  to  be  used,  the  opening  will  not  need  to  be  so  large  as  when 
drainage  of  a  less  rigid  material  is  employed.  The  tendency  of  the 
average  physician  is  to  make  the  opening  too  small.  The  direction 
of  the  incision  is  determined  first  by  the  course  of  important 
underlying  anatomic  structures,  and  should  run  parallel  to  them; 
a  transverse  incision  endangers  them  much  more.  If  no  import- 
ant structures  are  in  close  relation  to  the  abscess,  the  incision  should 
be  made,  especially  on  exposed  parts,  in  such  direction  as  to  give 


Fig.  24. — Incorrect  method  of  incising  finger. 

the  least  disfigurement,  namely,  in  the  direction  of  the  creases  of 
the  skin.  The  opening  should  extend  well  down  into  the  abscess 
cavity,  and  not  simply  puncture  it  at  the  bottom  of  the  incision. 
Hilton's  Method. — If  the  abscess  cavity  lies  beneath  a  dangerous 
region,  where  an  incision  could  not  be  safely  made  into  it,  it  is  best 
to  employ  Hilton's  method.  Make  an  incision  down  to  the  deep 
fascia  or  to  the  danger  zone;  pass  a  probe-pointed  grooved  director 
through  the  tissues  into  the  cavity;  its  entrance  can  be  recognized 
by  the  escape  of  pus  along  the  groove,  which  is  held  upward,  by 
the  lack  of  resistance  to  the  advancing  instrument,  and  by  the 
ability  to  make  lateral  movements  without  meeting  with  obstruc- 
tion, much  as  one  would  know  that  a  sound  had  passed  from  the 
urethra  into  the  bladder.  Pass  a  pair  of  closed  pointed  forceps 
along  the  groove  of  the  director  into  the  abscess  cavity,  open  them, 
and  withdraw  while  held  open.  This  tears  an  opening,  but  does 


SUPPURATION  161 

not  injure  the  vessels  and  nerves,  which  roll  or  slide  out  of  the  way 
of  the  forceps,  but  could  not  escape  a  sharp  knife. 

The  place  of  pointing  cannot  be  accepted  as  the  most  favorable 
point  for  opening  an  abscess.  The  incision  should  be  so  situated 
that  drainage  will  be  most  perfect  in  the  position  to  be  occupied 
subsequently.  Hence,  if  an  incision  is  made,  and  on  examination 
of  t  he  abscess  cavity  it  is  found  that  drainage  will  not  be  good,  a 
sen  mil  incision,  or  counteropening,  will  be  made  at  the  most  ad- 
vantageous point. 

Cleaning  the  Abscess  Cavity. — After  opening  an  abscess  the  pus 
may  be  removed  by  irrigation  with  normal  salt  solution  or  by 
mopping  with  sponges;  hydrogen  peroxid  may  be  used,  but  only 
when  the  opening  is  patent.  If  the  size  of  the  opening  is  large 
•  •IK  mgh  and  correctly  situated,  and  the  drainage  adequate,  it 
1 1  Kit  t  •  TS  little  whether  all  the  pus  is  cleaned  out  of  the  abscess  cavity, 


Fig.  25. — Correct  method  of  incising  finger. 


for.  the  pressure  off,  the  current  of  lymph  in  adjacent  vessels  is  re- 
newed and  the  drainage  will  take  care  of  the  discharge.  In  no 
MM  should  one  yield  to  the  temptation  to  squeeze  out  the  contents 
of  an  abscess,  for  by  so  doing  the  limiting  walls  of  leukocytes  may 
be  broken  up  and  a  direct  extension  of  the  infection  occur,  or  a 
thrombus  may  be  dislodged  from  the  mouth  of  a  vein  and  allow 
the  escape  of  pus  directly  into  the  circulation.  Moreover,  squeez- 
ing will  bruise  the  tissue  and  favor  necrosis.  The  application  of 
a  -licking  cup,  whose  diameter  is  greater  than  that  of  the  abscess, 
is  the  nii)-i  satisfactory  plan  of  evacuating  pus.  Removal  of  the 
••ore  from  furuncles  should  be  done  by  lifting  it  out  with  a  pair  of 
fnrceps;  if  firmly  attached,  heavy  traction  should  not  be  made  on  it, 
for  the  same  reasons  urged  against  squeezing.  In  a  day  or  two 
it  will  be  entirely  separated  and  may  bo  easily  lifted  out.  If  a  few 
points  are  held  by  fibrous  tissue  they  should  be  cut  rather  than  torn. 
11 


162  PRINCIPLES   OF   SURGERY 

Curetting  the  cavity  of  an  acute  abscess  is  an  unnecessary  and  may 
be  a  very  harmful  procedure.  So,  too,  the  use  of  escharotics  has 
little  or  nothing  to  recommend  it,  as  the  necrotic  material  will 
be  disposed  of  in  a  very  short  time  by  natural  processes.  If  a 
blood-clot  is  found  in  the  cavity  it  should  be  removed;  allowing  tune 
for  it  to  be  digested  by  the  bacteria  will  cause  unnecessary  delay. 

As  soon  as  reaccumulated  pus  has  filled  the  cavity,  or  as  soon 
as  the  dressings  have  become  soiled,  a  new  dressing  should  be 
applied  and  the  cleansing  process  repeated.  Cupping  at  the 
time  of  dressings  gives  the  double  advantage  of  withdrawing  the 
discharge  and  of  hyperemia.  The  dressings  should  be  changed  once 
a  day  in  ordinary  abscesses  and  oftener  in  large  ones. 

Drainage. — This  item  in  the  treatment  of  abscess  is  frequently 
advised  by  use  of  the  term  "pack,"  which  is  applied  too  literally. 
The  packing  should  not  be  tight;  its  object  is  to  accomplish  drain- 
age, and  it  should  be  placed  in  the  cavity  loosely,  and  so  distrib- 
uted as  to  wick  the  fluids  from  the  depths  of  the  abscess  most 


Fig.  26. — Drainage  material  ready  for  use. 

thoroughly.  There  is  only  one  circumstance  demanding  that 
tight  packing  be  done,  namely,  for  control  of  hemorrhage;  here  it 
must  be  done  tightly  enough  to  stop  the  bleeding,  and  must  not 
be  removed  until  conditions  demand  it;  even  then  it  is  to  be  re- 
moved with  extreme  caution,  lest  the  hemorrhage  be  re-established. 
Drainage  material  has  the  additional  object  of  maintaining  an 
adequate  opening  until  the  abscess  cavity  can  be  obliterated  by 
the  healing  process. 

The  material  used  for  drainage  is  manifold,  depending  on  the 
size  and  location  of  the  abscess.  In  small  abscesses,  where  it  is 
necessary  to  drain  only  for  a  few  days,  gauze  is  sufficient.  Medi- 
cated gauze,  especially  if  the  medicament  is  bulky  or  if  it  contains 
an  oily  menstruum,  does  not  drain  so  well  as  plain  sterile  gauze;  also, 
after  gauze  becomes  thoroughly  saturated  with  pus  and  the  meshes 
are  blocked  by  the  debris,  it  loses  its  capillarity  and  is  inefficient. 
Hence,  gauze  drains  should  not  be  allowed  to  remain  longer  than 
twenty-four  to  thirty-six  hours  without  changing.  When  packing 


SUPPURATION  163 

i-  u-ed  to  wall  off  spaces  in  serous  cavities  the  purpose  is  an  entirely 
different  one  am}  the  gauze  may  be  left  longer  in  situ.  Gauze 
drains,  as  well  as  others,  serve  their  purpose  better  when  covered 
wit  h  a  moist  dressing.  It  is  more  satisfactory  to  employ  specially 
made  gauze  with  two  selvage  edges  for  drainage.  It  is  easier  to 
introduce,  leaves  no  frazzles  behind  when  removed,  and  does  not 
tear  so  easily  during  removal.  When  large  cavities  are  packed  with 
gauze  an  accurate  account  of  the  number  of  pieces  must  be  kept, 
or  the  end  of  each  successive  piece  should  be  fastened  (usually  by 


Fig.  27. — Glass  drainage-tubes. 

tying)  to  the  end  of  the  preceding  piece;  or,  if  introduced  sepa- 
rately, the  end  of  each  piece  should  be  held  outside  the  wound, 
and  all  secured  together  at  the  end  of  the  dressing. 

Drainage  of  slight  quantities  may  be  done  by  the  introduction 
of  a  few  strands  of  thread. 

Drainage  by  tubes  is  the  second  widely  employed  method. 
Drainage-tubes  are  usually  made  of  soft  rubber,  hard  rubber,  or 
glass,  occasionally  of  metal.  The  soft-rubber  tubes  are  usually 


Fig.  28. — Metal  drainage-tubes. 

preferred,  except  where  there  is  danger  of  collapsing  the  tube  by 

external  pn—  lire,  as  in  deep  drainage  of  the  pelvis  through  the 
abdominal  opening.  These  may  be  used  as  a  single  tube,  or  split 
longitudinally  or  spirally  with  a  strip  of  gauze  placed  within  the 
lumen  and  allowed  to  project  an  inch  at  either  end,  or  the  deep 
end  of  the  tube  may  be  perforated  at  short  intervals,  so  that,  if  the 
end  of  the  tube  should  be  blocked,  drainage  may  be  continued. 

tubes  may  be  perforated  in  the  same  manner. 
If  drainage  is  insufficient,  aspiration  may  be  done  by  intro- 


164  PRINCIPLES   OF   SURGERY 

ducing  a  long  syringe  nozzle  or  a  rubber  tube  and  aspirating  the 
contents  as  rapidly  as  they  accumulate.  This  is  especially  neces- 
sary in  drainage  of  the  peritoneal  cavity. 

The  maintenance  of  tubes  in  position  is  a  very  important,  often 
a  very  troublesome,  feature  of  drainage.  This  obstacle  may  be 
overcome  by  suturing  the  tube  to  the  skin  and  fascia  at  the  edge 
of  the  wound.  The  suture  should  not  be  drawn  closely,  as  it  is 
likely  to  cut  out.  Mixter's  tubes  and  T-tubes  are  used  to  prevent 
their  escape  from  the  cavity,  and,  where  a  suture  is  placed  in 
addition,  they  can  escape  hi  neither  direction.  The  rubber  spool 
is  another  very  satisfactory  device  to  prevent  displacement  of  the 
drainage  apparatus. 

Treatment  of  Carbuncle. — In  carbuncles  the  accepted  treat- 
ment is  a  crucial  incision  into  the  mass,  cleansing,  and  drainage  by 
gauze  packing.  The  necrotic  mass  and  all  tissue  evidently  about 
to  necrose  should  be  removed  with  the  scissors,  knife,  or  very 
sharp  curet,  otherwise  drainage  is  very  likely  to  be  imperfect,  and 
extension  of  the  carbuncle  into  surrounding  tissue  will  continue 
uninterrupted.  The  danger  of  carbuncle  to  life  is  much  greater 
than  that  of  simple  abscess,  and  accordingly  the  incision  must  be 
free  and  the  removal  of  tissue  extensive.  Another  method  of 
treatment,  offering  a  surer  prognosis  and  no  longer  average  time  for 
recovery,  is  excision  of  the  entire  inflamed  mass,  and  subsequent 
treatment  of  the  open  wound,  followed  by  skin-grafting  if  neces- 
sary. 

The  treatment  of  a  whitlow  should  be  inaugurated  at  the  earliest 
possible  moment  after  recognition  of  its  true  nature.  A  long  deep 
incision  should  be  made  and  packed  with  gauze.  It  is  often  neces- 
sary to  employ  in  these  cases  the  additional  treatment  laid  down 
under  Inflammation,  especially  moist  heat. 

In  cases  of  multiple  abscess,  in  furunculosis,  in  those  who  seem 
to  have  a  general  weakness  against  a  particular  pus-producing 
organism  (the  most  common  cause  in  these  cases  is  Staphylococcus 
pyogenes  aureus),  and  in  every  case  of  carbuncle  that  does  not  show 
the  most  prompt  response  to  treatment  it  is  imperative  that  im- 
mediate efforts  should  be  made  to  raise  the  individual's  resistive 
powers  by  nourishment,  rest,  and  tonics,  but  especially  by  the 
administration  of  the  vaccines  indicated.  These  can  be  purchased 
in  all  the  cities  at  prices  within  the  reach  of  all.  Opsonic  indices, 
cultures,  and  specially  prepared  vaccines  are  unnecessary  in  most 
instances,  and  the  selection  of  the  proper  vaccine,  streptococcus, 
staphylococcus,  or  polyvalent  can  usually  be  done  satisfactorily  by 
clinical  observation  alone. 


CHAPTER  VI 
SEPSIS 

THE  term  "sepeis"  is  used  to  signify  the  general  or  constitutional 
condition  produced  by  the  action  of  pyogenic  and  of  saprogenic 
bacteria.  There  are  three  fairly  distinct  types  of  sepsis,  which  are 
septic  intoxication  (sapremia),  septic  infection  (septicemia),  and 
pyemia. 

SEPTIC  INTOXICATION   (SAPREMIA) 

Septic  intoxication  and  sapremia  represent  the  first  group, 
and  are  the  simplest  type  of  the  septic  condition  considered  from 
tin  standpoint  of  pathology,  prognosis,  or  treatment.  They  are 
usually  given  as  synonyms,  but  usage  has  gradually  separated 
them  into  fairly  distinct  terms;  still  they  are  sufficiently  similar  to 
be  treated  under  the  same  heading  when  each  is  throughly  defined. 

Septic  intoxication  is  the  constitutional  impression  made  by  the 
aK-orption  of  the  poisons  produced  by  pyogenic  bacteria  in  the 
tis-ues.  The  pathology  serving  as  the  primary  cause  of  septic  in- 
toxication, then,  isalocalized  inflammatory  or  suppurative  process. 
From  this  the  poisons  are  absorbed,  carried  into  the  general 
circulation,  and  produce  the  varying  pictures  of  intoxication.  The 
bacteria  do  not  gam  entrance  into  the  blood  in  great  numbers  and 
arc  not  recoverable  from  it;  there  is  not  a  wide  distribution  of  the 
infection  beyond  the  local  extension.  So  septic  intoxication  may 
l.i  accepted  as  a  term  used  to  represent  the  constitutional  symp- 
toms of  a  local  suppurative  or  inflammatory  process.  The  general 
symptoms  developed  in  the  course  of  an  acute  abscess  are  symptoms 
of  septic  intoxication;  so  are  the  constitutional  symptoms  of 
erysipelas,  of  appendicitis,  of  pelvic  inflammations,  etc. 

Sapremia  is  similarly  produced  by  the  absorption  of  bacterial 
po'i-ons  from  a  localized  infection.  The  nature  of  the  infection  is 
different.  In  septic  intoxication  the  bacteria  are  pyogenic,  in 
-apremia  they  are  saprophytic,  or,  at  most,  a  mixed  infection  of 
saprophytes  and  pyogenic  bacteria.  Therefore,  in  sapremia 
decomposition  of  tissue  or  of  tissue  products  is  going  on  in  the 
primary  focus,  while  in  septic  intoxication  inflammation  or  sup- 
puration is  the  local  pathology.  If  both  types  of  infection  are 
pre-ent.  -apremia  is  the  term  commonly  applied.  Hence,  -apremia 
i-  u-ually  seen  associated  with  decomposition  of  blood-clots  and 

Iff 


166  PRINCIPLES   OF   SURGERY 

secundines  subsequent  to  unclean  abortions  and  deliveries,  to  the 
accumulation  of  blood  and  necrosis  in  operative  and  traumatic 
wounds,  and  to  gangrene. 

Pathology. — The  local  changes  are  sufficiently  indicated  by 
the  above  descriptions  of  septic  intoxication  and  sapremia.  In 
these  conditions  the  inflammatory,  suppurative,  or  decomposition 
process  is  capable  of  causing  intoxication  in  direct  proportion  to 
the  virulence  of  the  infection,  the  extensiveness  of  the  lesion,  and 
the  rate  of  absorption.  Often,  therefore,  a  very  limited  lesion  may 
produce  violent  symptoms,  whereas  an  extensive  process  situated 
elsewhere  will  result  hi  insignificant  ones.  The  measure  of  the 
danger,  therefore,  in  either  instance  is  the  constitutional  im- 
pression produced,  except  in  those  instances  where  the  nature  of 
the  infection  or  the  vital  importance  of  the  structure  affected  ren- 
ders the  outlook  unfavorable  regardless  of  the  general  symptoms. 

The  chief  bacteria  found  in  sapremic  foci  are  the  proteus  group, 
Bacillus  pyocyaneus,  and  Micrococcus  tetragenes. 

The  general  pathology  of  sapremia  and  septic  intoxication 
may  be  given  in  a  single  paragraph  if  one  recalls  that  in  sapremia 
the  infection  is  chiefly  represented  by  the  bacteria  of  decompo- 
sition, probably  rarely  without  an  admixture  of  pyogenic  micro- 
organisms, and  that  in  septic  intoxication  the  infection  is  of  a  purely 
pyogenic  nature.  The  most  striking  detail  of  the  general  pathol- 
ogy in  these  cases  is  the  alteration  of  the  blood-picture,  which 
may  be  accepted  as  a  fair  index  of  the  constitutional  impression 
made.  The  leukocyte  count  is  likely  to  be  increased  except  in 
case  of  absorption  of  overwhelming  quantities  of  poison.  On  the 
other  hand,  the  hemoglobin  is  reduced  and  the  number  of  red  cells 
is  diminished,  caused  by  the  hemolytic  action  of  the  poisons, 
which  explains  the  cachectic  appearance  of  septic  individuals. 
If  the  process  becomes  chronic,  amyloid  changes  occur  in  the  liver, 
spleen,  kidneys,  intestines,  and  blood-vessels.  The  clinical  evi- 
dence of  extensive  amyloid  changes  is  shown  by  enlarged  liver  and 
spleen,  albumin  and  waxy  casts  in  the  urine,  and  low  blood-pres- 
sure. Petechiae  are  at  times  found  in  these  types  of  sepsis,  as  well 
as  submucous  and  subserous  hemorrhages,  although  they  are  less 
frequent  in  sapremia  and  septic  intoxication  than 'in  septicemia 
and  pyemia. 

Symptoms. — The  symptoms  of  septic  intoxication  are  those 
detailed  under  Inflammation  and  Pus  absorption.  The  symptoms 
of  sapremia  are  closely  allied,  and  are  as  follows:  As  a  rule,  the 
initial  symptoms  manifest  themselves  within  twenty-four  to  forty- 
eight  hours  subsequent  to  infection  of  devitalized  tissue,  clots,  or 
serum  which  have  accumulated  in  some  cavity  of  the  body.  There 
may  be  an  initial  chill,  but  its  absence  has  no  diagnostic  signifi- 


SEPSIS  107 

cance.  The  temperature  rapidly  rises,  often  as  high  as  104°  to 
106°  F.,  and  the  pulse  is  rapid.  It  may  be  safely  stated  that  there 
arc  n»>  -thenic  cases  of  sapremia.  The  blood-pressure  is  reduced. 
If  the  condition  continues  unabated  or  grows  worse  the  pulse  be- 
« t.nics  exceedingly  rapid  and  thready  and  may  be  dicrotic.  The 
temperature  fluctuates,  but  does  not  show  the  wide  variations  of 
sept  ic  intoxication  or  of  pyemia.  The  skin  is  cold  and  clammy  and 
i-  at  time-  leaky.  The  appetite  is  lost  and  emaciation  is  in- 
credibly rapid.  There  may  be  constipation,  but  it  is  not  unusual 
an  exhaustive  diarrhea,  probably  the  expression  of  an  intense 
efi'ort  of  nature  at  elimination.  The  subcutaneous  fat  is  rapidly 
the  features  expressionless  or  drawn,  the  nose  pinched,  the 
countenance  pale,  with  cyanotic  lips.  The  cheeks  are  hollow,  the 
are  sunken,  and  the  patient  represents  a  ghastly  picture  of 
anxiety  or  of  unutterable  suffering.  Such  is  known  as  the  hippo- 
cratic  facies.  The  respiration  is  quick  and  short.  Frequently 
valuable  aid  may  be  rendered  in  making  the  diagnosis  if  one 
observes  the  presence  of  the  odor  of  putrefaction.  As  the  disease 
progresses  mental  symptoms,  such  as  delirium  and  coma,  which 
often  resemble  those  of  typhoid  fever  very  closely,  or  nervousness, 
develop,  and,  unless  speedy  relief  can  be  had,  a  few  days  will 
Miffice  to  terminate  the  scene  in  death. 

Prognosis. — In  cases  of  sapremia  especially,  and  in  most  cases 
•  >t  ic  in t « >xication,  where  vital  structures  are  not  crippled  by  the 
primary  lesion,  the  prognosis  is  the  very  best.  There  is  no 
condition,  perhaps,  where  more  visible  results  of  the  physician's 
prompt  action  are  seen  than  here.  But  one  must  always  guard  one's 
self  with  the  warning  that  in  these  cases  septicemia  or  pyemia  may 
l>e  ushered  in  at  any  moment,  the  seeds  of  which  may  be  already 
>o\vn  at  the  time  of  diagnosis. 

Treatment. — The  treatment  of  septic  intoxication  is  that  of  the 
inflammatory  or  suppurative  process  which  causes  it.  These  sub- 
ject-  have  already  been  dealt  with  at  length. 

The  treatment  of  the  sapremia  is,  above  all  things,  urgent; 
no  delay  can  be  had;  what  needs  to  be  done  must  be  done  at  once. 
To-morrow  may  prove  fatal.  The  order  is  diagnosis,  then  treat- 
ment immediately.  An  anesthetic  should  not  be  given  unless 
absolutely  necessary,  except  hi  those  whose  vital  resources  are 
not  nraring  exhaustion.  If  anesthesia  must  be  used,  it  should  be 
u-cd  a<  >paringly  as  possible.  The  focus  of  infection  must  be 
cleaned  »>ut  thoroughly,  irrigated  if  necessary,  but  this  is  often  a 
\\a-te  of  time,  and  adequate  drainage  instituted;  the  work  should 
lie  dour  as  hastily  as  is  compatible  with  thoroughness;  after  opera- 
tion it  i<  very  necessary  to  prevent  accumulation  of  discharges; 
if  the  drainage  will  not  take  care  of  the  di-charg<-.  irrigation  must 


168  PRINCIPLES   OF   SURGERY 

be  resorted  to;  and  here  the  use  of  antiseptic  solutions  may  be 
especially  valuable,  as  the  bacteria  are  not,  as  a  rule,  buried  in  the 
tissues  except  hi  gangrenous  conditions.  Whether  the  general 
condition  of  the  patient  demands  it  or  not,  it  is  frequently  neces- 
sary to  use  deodorizing  irrigation  for  the  comfort  of  both  patient 
and  attendants;  the  same  end  is  likewise  accomplished  by  packing 
the  cavity  loosely  with  gauze  saturated  with  50  per  cent,  alcohol, 
which  is  perhaps  the  most  satisfactory  plan,  permanganate  of 
potash  solutions,  1  :  5000,  or  kresol  or  lysol  in  1  per  cent,  solutions. 
These  solutions  are  very  satisfactory  also  for  irrigation,  as  they 
combine  antiseptic  with  deodorizing  properties. 

General  Treatment. — General  treatment  is  directed  along  two 
lines,  namely,  to  hasten  elimination  of  the  poisons  and  to  stimulate 
the  vital  functions  until  this  is  accomplished.  Even  in  apparently 
violent  cases  the  transformation  in  the  course  of  a  few  hours 
wrought  by  local  treatment  is  marvelous,  inasmuch  as  the  elimi- 
nation of  the  bacterial  poisons  is  very  rapid.  But  if  it  is  necessary 
to  assist  nature  in  such  elimination,  the  utmost  precaution  is 
needed.  Purgation  of  an  exhausted  patient,  such  as  one  sees  in 
sapremia,  can  prove  quickly  fatal.  If  the  bowels  must  be  moved, 
let  it  be  by  high  enemata.  The  only  safe  route  of  elimination  should 
be  by  the  kidneys,  and  the  remedy  is  water.  Normal  salt  solution 
must  be  administered  in  great  abundance  by  mouth,  by  hypocler- 
moclysis,  by  intravenous  injection,  by  large  retained  enemata 
frequently  repeated,  or  drip  enemata.  This  method  of  elimination 
does  not  increase  the  exhaustion,  whereas  sweating  and  purgation 
do.  In  the  more  serious  cases,  in  which  extensive  disintegration  of 
the  red  corpuscles  have  taken  place,  direct  transfusion  of  blood 
should  be  resorted  to  without  delay.  It  is  better  to  perform  this 
operation  at  the  same  sitting,  if  possible,  with  that  for  removal  of 
the  infected  focus. 

Stimulation  is  usually  needed  and  is  produced  by  the  admin- 
istration of  strychnin,  whisky,  and  adrenalin  chlorid.  In  the  use 
of  the  latter  drug  its  brief  period  of  efficiency  is  to  be  remembered, 
and  the  doses  should  be  repeated  every  two  or  three  hours. 

Nutritious,  easily  assimilated  diet  must  be  administered  in  as 
great  quantity  as  the  digestive  organs  can  dispose  of  comfortably. 

The  crisis  lasts  a  few  hours  and  demands  the  greatest  vigilance. 
If  the  temperature  fails  to  come  to  normal  soon  after  cleaning  away 
the  putrid  material  it  may  be  accepted  as  signifying  that  the  work 
was  incomplete,  that  a  septicemia  has  already  been  inaugurated, 
or  that  some  complication  is  present.  A  rise  of  the  temperature 
after  it  has  become  and  remains  normal  a  few  hours  indicates  the 
need  of  dressing  and  irrigation.  After  the  crisis  is  past  a  tonic  and 
dietetic  regime  will  be  followed  until  the  normal  status  is  reached. 


SEPSIS  169 

SEPTICEMIA  OR  SEPTIC   INFECTION 

The  second  subdivision  of  septic  conditions,  septicemia,  is, 
while  often  difficult  to  distinguish  clinically  from  the  preceding, 
pathologically  widely  separated  from  it.  In  the  preceding  condition 
the  local  process  is  the  important  lesion;  in  the  latter,  whether 
the  local  changes  be  important  or  so  insignificant  as  to  be  undis- 
coverable,  they  are  nothing  as  compared  with  the  essential  feature. 

Septicemia  is  the  presence  of  bacteria,  usually  pyogenic,  in  the 
blood  in  sufficient  quantity  to  constitute  a  diseased  condition 
of  that  fluid.  In  almost  any  local  infection  it  is  doubtful  if  the 
blood  ever  escapes  the  presence  of  a  few  bacteria,  but  they  are  not 
pre>ent  in  such  quantities  as  to  be  recoverable  and  are  soon  elimi- 
nated by  the  kidneys  or  liver.  So,  too,  in  many  constitutional 
diseases,  such  as  the  infectious  fevers,  the  blood  may  contain  vast 
numbers  of  bacteria,  even  the  bulk  of  them,  as  in  bacteremia. 
They  are  not  to  be  confused  with  septicemia,  which  is  a  constitu- 
tional condition  produced  by  bacteria,  whose  action  is  for  the  most 
part  local,  but  not  necessarily  pyogenic. 

Cause. — As  has  been  intimated  before,  certain  bacteria  are 
prone  to  produce  spreading  infections  and  septicemia,  others  may 
do  -o,  and  still  others,  poorly  pathogenic  and  capable  of  invading 
ti— ues  only  when  their  resistance  is  reduced,  would  scarcely  be 
at'le  to  cause  a  general  hematic  infection  under  the  most  favorable 
circumstanees. 

The  bacteria  most  frequently  recovered  from  the  blood  and 
viscera  of  septicemic  patients  are  streptococci.  In  addition  to 
streptococci,  Staphylococcus  albus  or  aureus,  pneumococcus,  Ba- 
cillus coli  communis,  Bacillus  diphtheria,  gonococcus,  and  several 
of  t  he  anaerobes,  especially  Bacillus  aerogenes  capsulatus,  Bacillus 
typhosus,  and  Bacillus  pyocyaneus,  may  be  given  as  causes  of  sep- 
ticemia. Some  of  these  bacteria  usually  produce  a  disease,  as, 
for  instance,  Bacillus  typhosus  and  pneumococcus,  but  they  may 
produce  local  and  hematic  infections  as  well,  and  show  then  not 
the  characteristics  of  their  specific  disease,  but  a  true  septicemia. 
Proteu-  vulgaris  has  been  recovered  from  the  blood  of  septicemic 
patient-. 

Pathology. — The  primary  lesion  may  vary  from  the  most  insig- 
nificant scratch  or  prick — cryptogenetic  cases  are  reported — to 
the  most  violent  inflammatory  processes.  The  atrium,  in  case  it 
is  a  wound,  may  paradoxically  enough  show  no  reaction  from  the 
infection,  and  he  healed  in  the  few  days  that  elapse  before  septi- 
cemic  -ymptoms  develop.  This  explains  the  so-called  idiopathic 
septicemia.  The  condition-  serving  as  atria  of  infection  for  sep- 
ticemia an-  \\ounds,  uterine  infections  following  abortions  and 


170  PRINCIPLES   OF   SURGERY 

deliveries,  abscesses,  acute  osteomyelitis,  and  erysipelas,  together 
with  lesions  produced  by  the  specific  micro-organisms  which  occa- 
sionally or  habitually  result  hi  a  localized  inflammation.  A  num- 
ber of  cases  of  suppurative  inflammation  of  the  thoracic  duct  have 
been  described,  usually  unmistakably  secondary  to  infections  in  the 
distribution  of  radicals  in  the  pelvis,  and  the  chyle  vessels  hi  the 
alimentary  tract.  A  few  cases  of  primary  suppuration  of  the 
thoracic  duct  have  been  reported.  It  is  superfluous  to  say  that 
such  a  condition  could  scarcely  fail  to  result  hi  septicemia  or  py- 
emia.  The  only  evidence  so  far  advanced  is  the  continuous  in- 
crease of  the  leukocyte  count  to  an  enormous  number,  even  as 
high  as  200,000. 

Entrance  of  Bacteria  into  Circulation. — From  a  surgical  stand- 
point, by  far  the  greater  number  of  cases  of  septicemia  result  from 
the  escape  of  bacteria  from  an  infected  wound,  from  decomposing 
blood-clots,  or  gangrenous  tissues.  Septicemia  was  a  frequent 
complication  of  hospital  gangrene  before  this  disease  was  practically 
blotted  from  the  list  of  surgical  conditions.  It  may  follow  closely 
on  the  development  of  acute  infections,  which  can  be  explained  only 
on  the  hypothesis  that  bacteria  have  gained  access  to  the  blood, 
in  all  probability  through  the  mucous  membrane,  and  lodged  at  the 
site  of  an  insignificant  injury,  as  is  illustrated  by  acute  cases  of 
osteomyelitis,  which  may  terminate  in  a  fatal  septicemia  before 
the  local  process  has  had  time  to  suppurate.  From  the  local 
infection  the  bacteria  may  invade  the  general  circulation,  either 
through  the  lymphatics  or  by  escape  into  the  blood-vessels,  as 
happens  when  an  abscess  ruptures  into  a  vein. 

General  Pathology. — The  essential  feature  of  the  general  patho- 
logic picture  of  septicemia  is  that  the  blood  contains  the  bacteria, 
a  statement  questioned  by  authors  who  believe  that  their  ap- 
pearance in  the  blood  is  accidental  and  inconstant,  and  that  the 
fundamental  pathology  is  the  presence  of  numberless  small,  often 
microscopic,  foci  of  infection  scattered  through  the  tissues  by  the 
blood,  which  is  only  the  distributing  medium  and  not  the  tissue 
primarily  concerned  in  septicemia.  The  spleen  is  enlarged. 

The  infection  hi  cases  of  septicemia  may  produce  no  lesion 
further  than  the  cloudy  swelling,  or,  if  chronic,  the  amyloid  changes 
and  the  hemolytic  changes  as  described  previously  under  Sapremia. 
On  the  other  hand,  frequently  a  septic  endocarditis  complicates  the 
general  infection,  and  produces  local  and  general  symptoms  and 
signs  in  keeping  with  the  changes  produced  in  the  valves  of  the 
heart.  However,  even  in  the  most  violent  cases  of  septicemia  the 
valves  may  remain  normal.  This  endocarditis  may  affect  either 
the  mitral  or  the  tricuspid  valves,  the  former  more  frequently. 
Even  in  mild  cases  of  septicemia  the  development  of  malignant 


SEPSIS  171 

endocarditis  will  add  greatly  to  the  unfavorable  prognosis,  but  even 
with  this  complication  some  cases  may  not  be  hopeless.  If 
miliary  abscesses  develop  they  appear  in  great  numbers,  and  are 
fo\i ml  scattered  throughout  the  body,  in  the  marrow,  bones,  central 
nervous  system,  glands,  and  the  abdominal  and  thoracic  viscera. 
Again,  the  distribution  of  the  miliary  foci  may  be  very  partial, 
>ho\ving  up  in  great  numbers,  for  example,  in  the  lungs  and  liver, 
and  very  slightly  in  other  viscera.  There  is  frequently  a  universal 
enlargement  of  the  lymph-nodes. 

The  Blood-count. — A  polymorphonuclear  leukocytosis  is  usually 
ptv-ent,  although  in  the  most  severe  cases  it  is  absent.  Mention 
is  made  above  of  the  enormous  count  attained  in  suppuration  of  the 
thoracic  duct. 

Symptoms. — The  interval  between  the  date  of  primary  infec- 
tion  and  the  development  of  septicemia  varies  from  a  few  hours  to 
several  days.  The  facts  can  best  be  comprehended  by  remember- 
ing that  usually  a  local  inflammatory  process  precedes  septicemia. 
The  time  required  for  this  to  take  place  then  intervenes,  and  sep- 
t  icemia  will,  therefore,  not  develop  as  soon,  on  an  average,  after  the 
primary  infection  as  a  sapremia  would.  Usually  the  time  required 
is  from  forty-eight  hours  up.  Still  those  rapid  cases  must  not  be 
f«  >rg»  >tten  in  which  at  no  time  a  primary  inflammation  develops,  but 
the  bacteria  are  delivered  in  the  shortest  possible  time  into  the 
circulation.  These,  of  course,  would  develop  rapidly  (occasionally 
in  a  few  hours),  and  may  run  a  fatal  course  in  three  or  four  days  if 
the  number  of  bacteria  introduced  is  large.  On  the  contrary,  it  is 
p<  >-<ible  for  a  septicemia  to  develop  at  any  time  while  there  remains 
a  -uppurative  focus  in  the  body. 

<  »n  observation  of  a  patient  who  has  septicemia  the  pallor, 
the  listiessness,  the  yellowish  cachectic  appearance,  the  drawn 
f<atun-  and  the  dilated  nostrils,  the  rapid  respiration,  and  the 
great  emaciation  are  very  striking.  Septicemia  quickly  gives  the 
patient  the  appearance  of  having  been  ill  for  a  long  time.  The 
general  appearance  is  that  of  great  prostration.  The  eyes  are 
sunken,  the  cheeks  hollow,  and  the  bony  prominences  stand  out  in 
undue  relief;  cyanosis  is  also  often  present  and  the  patient  is 

U-ually  re>tle.-s. 

At  the  beginning  the  skin  is  dry  and  hot,  and,  as  the  disease 
advances,  perspiration  may  take  place,  either  a  constant  moisture 
of  the  Mirface,  which  gives  it  a  cold,  clammy,  repulsive  feel,  or  the 
per-piration  may  be  drenching.  In  other  cases  the  skin  remains 
dry  throughout.  There  appear  at  times  various  cutaneous  erup- 
tion- resembling  scarlatina,  urticaria,  or,  it  may  be,  a  pustular 
eruption.  Icterus  may  be  distinct  and  petechise  are  often  ob- 

>erved. 


172  PRINCIPLES   OF   SURGERY 

The  Temperature. — As  in  all  reactions  caused  by  bacteria,  the 
temperature  rises  in  septicemia,  frequently  preceded  by  an  initial 
chill,  but  by  no  means  constantly.  The  chill  is  not  likely  to  be 
repeated.  The  temperature  rises  gradually  in  those  cases  where 
the  infection  is  brought  slowly  into  the  circulation,  very  rapidly  in 
most  acute  cases  in  which  large  numbers  of  bacteria  are  admitted 
at  once.  The  chart  shows  the  temperature  usually  as  a  continued 
fever,  with  slight  elevation  of  the  evening  over  the  morning 
temperature.  High  degrees  are  often  reached,  and  in  the  worst 
cases  a  subnormal  temperature  is  observed.  In  chronic  cases  the 
temperature  may  range  from  99^°  to  101°  or  102°  F.,  and  continue 
many  weeks  without  coming  to  normal.  When  conditions  are 
present  which  might  cause  a  septic  intoxication  or  sapremia,  and 
the  proper  local  treatment  fails  to  bring  the  temperature  to  normal 
or  nearly  so,  it  is  very  suggestive  of  hematic  infection.  In  the 
course  of  a  suppurative  or  infective  process  a  persistent  elevation 
of  the  temperature,  after  a  satisfactory  progress  for  some  time, 
should  stimulate  an  immediate  investigation  of  the  cause.  As  the 
condition  improves  there  is  a  gradual  subsidence  of  the  temperature 
to  or  below  normal. 

Pulse  and  Blood-pressure. — Little  disturbances  of  the  pulse, 
beyond  a  slight  acceleration,  is  observed  in  the  mild  cases,  but  in  the 
severe  forms  the  pulse  is  unduly  rapid  and  the  blood-pressure  is 
low,  as  shown  by  employment  of  the  sphygmomanometer  or  by 
the  softness  and  compressibility  of  the  pulse.  High  pulse-rate  in 
proportion  to  the  temperature  is  frequent  in  septicemia  and  is  an 
ill  omen,  for  it  shows  exhaustion  of  the  cardiac  centers.  This 
combination  finds  its  worst  form  in  the  subnormal  temperature 
and  the  rapid,  thready,  often  dicrotic  pulse  which  can  scarcely  be 
felt  or  counted.  The  condition  of  the  pulse  and  the  loss  of  blood- 
pressure,  together  with  the  general  appearance  of  the  patient,  are 
the  most  important  symptoms  of  septicemia.  The  lips  are  parched 
and  cracked,  the  tongue  is  dry,  and  sordes  are  found  upon  the 
teeth  unless  the  course  is  very  rapid. 

Great  thirst  is  present,  which  it  seems  impossible  to  satisfy. 
Nausea  is  present  and  vomiting  may  occasionally  occur,  or  may  be 
continual  and  violent.  Certain  cases  closely  reproduce  choleraic 
symptoms.  Anorexia  is  present,  as  in  all  septic  conditions;  it  is 
complete  in  septicemia.  Diarrhea  is  usually  present  and  at  times 
the  motions  contain  blood.  Involuntary  passage  of  urine  and 
feces  is  occasionally  observed. 

The  urine  is  scanty  and  high  colored,  and  contains  albumin, 
often  abundantly,  and  casts.  The  causative  micro-organisms  can 
often  be  discoverer!  in  it.  In  many  cases  pains  of  a  cramp-like 
nature  are  present  in  the  extremities,  and  there  may  be  headache. 


SEPSIS  173 

In  prolonged  cases  of  septicemia,  decubitus  must  be  constantly 
guarded  against,  as  the  tissues  are  poorly  resistant,  and  the  rapid 
emaciation  brings  the  bony  prominences  close  to  the  surface. 
The  wound,  if  one  be  present,  sometimes  assumes  almost  distinct 
characteristics;  granulations  do  not  appear,  and,  if  they  were 
pre-ent  at  the  beginning,  are  soon  lost,  and  the  surface  of  the 
wound  is  covered  with  a  false  membrane  of  necrotic  tissue,  inter- 
mingled with  which  is  more  or  less  fibrin.  This  is  especially  true 
of  streptococcic  cases.  This  necrosed  tissue  is  yellowish,  gray,  or 
dark  in  color;  suppuration  is  absent,  or  ceases  if  it  has  been  present, 
and  the  surface  of  the  wound  is  olry.  In  very  acute  cases  little 
change  of  the  appearance  of  the  wound  is  noted. 

Prognosis. — What  the  outcome  of  a  given  case  of  septicemia 
will  be  is  problematic.  All  the  rapid  acute  cases  die,  a  few  of  the 
HI!  acute  get  well,  and  the  outlook  is  best  of  all  in  the  chronic 
.  One  may* briefly  summarize  the  prognosis  by  stating  that 
practically  all  untreated  cases  die,  and  that  some  recover  if  treated 
assiduously. 

Treatment. — The  prevention  of  septicemia  is  one  of  the 
surgeon's  chief  cares.  Asepsis  is  the  method  of  prevention  in 
operative  work,  and,  following  as  a  close  second,  is  the  avoidance 
of  accumulations  of  blood  or  serum  which  may  become  infected; 
this  prevention  is  to  be  done  by  complete  hemostasis  or  by  drainage. 
Again,  by  the  avoidance  of  injury  to  the  tissues  by  undue  tearing, 
lac. -ration,  or  bruising  the  possibility  of  septicemia  is  reduced. 
All  these  favor  infection,  even  under  the  most  aseptic  •  condi- 
tions. There  is  no  place  in  modern  work  for  the  ignorant,  heavy- 
handed,  careless  surgeon.  Once  again,  the  surgeon  must  ever  be 
alert  to  see  and  quick  to  act  upon  conditions,  usually  hyperacute 
owing  to  intense  bacterial  virulence,  which  so  frequently  are  com- 
plicated by  septicemia,  and  to  have  the  utmost  care  that  a  wound 
that  was  guarded  with  the  most  zealous  watchfulness  during  the 
operation  is  not  infected  at  some  subsequent  dressing,  by  some 
careless  nurse  or  assistant  or  by  himself.  Too  frequently,  indeed, 
surgeons  do  not  surround  their  after-treatment  with  the  same 
judicious  restrictions  that  are  used  hi  the  operating  room.  The 
use  of  dilute  tincture  of  iodin  on  the  tissues  at  each  dressing  is 
perhaps  the  >ure>t  guarantee  against  a  late  infection.  The  acute 
conditions  demanding  prompt  action  are  particularly  acute  osteo- 
myelitis and  epiphysitis,  ('specially  in  the  young;  middle-ear  in- 
fectious nnd  suppuration,  or  even  non-suppurative  inflammation 
of  the  mastoid  cells;  acute,  virulent  infection  of  the  uterus  and  the 
adnexa  and  thrombophlebitis,  especially  affect  ing  the  large  pelvic 
veins  or  the  cerebral  sinuses  or  veins  trilmtary  to  them.  Acute 
suppurative  peritonitis,  spreading  traumatic  gangrene,  and  micro- 


174  PRINCIPLES   OF   SURGERY 

bic  gangrene  following  compound  fractures  should  be  included 
in  this  dangerous  list. 

The  details  of  treatment  for  these  various  conditions  would  lead 
us  too  far  afield  into  general  surgical  treatment.  But  whether 
septicemia  has  already  developed,  or  the  intention  is  to  prevent  it, 
two  fundamental  items  of  treatment  must  be  utilized,  namely, 
the  removal  of  the  infected  focus  completely,  if  not  prevented  by  the 
patient's  general  condition  and  by  the  location  and  extent  of  the 
focus;  and,  second,  such  treatment  by  drainage,  ligation,  etc., 
as  will  render  the  escape  of  bacteria  into  the  blood  less  likely, 
or,  if  they  have  already  begun  to  enter,  to  check  the  process  in 
statu  quo.  Fearless  and  extensive  surgical  measures,  in  keeping 
with  the  general  condition  of  the  patient,  are  more  urgent  here 
than  in  any  other  pathologic  condition,  malignancy  alone  excepted. 
Remove  if  possible;  if  not,  then  create  a  drainage  current  away 
from  rather  than  toward  the  circulation.  The  local  use  of  anti- 
septics is  indicated  where  they  can  possibly  be  applied.  Car- 
bolic acid  and  bichlorid  and  alcohol  are  the  favorites,  but  it  is 
difficult  to  see  of  what  value  they  can  be  beyond  the  immediate 
surface  of  application. 

The  general  treatment  of  septicemia  is  directed  along  very 
definite  lines,  but  the  means  at  the  surgeon's  command  are  limited 
both  hi  application  and  in  efficiency.  The  aim  of  treatment  is  to 
eliminate  the  bacteria  and  their  toxins  as  rapidly  as  possible,  to 
destroy  the  bacteria  or  neutralize  their  toxins  in  the  blood — i.  e.,  to 
render  the  blood  sterile — and,  finally,  to  maintain  the  patient's 
vitality  until  such  results  can  be  effected. 

The  elimination  of  toxins  and  bacteria  must  be  done  chiefly 
by  the  administration  of  water ;  therapeutic  and  other  measures  to 
produce  diaphoresis  and  purgation  are  too  prostrating  to  be  at- 
tempted, so  water  by  rectum  and  by  mouth,  and  intravenous 
or  subcutaneous  injection  of  normal  salt  solution,  is  the  chief 
reliance. 

The  destruction  of  bacteria  and  neutralization  of  toxins  is 
successful  to  a  limited  degree,  dependent  largely  upon  the  specific 
micro-organisms  and  upon  our  ability  to  determine  what  species 
the  infection  belongs  to.  If  a  mixed  infection  is  present,  any  spe- 
cific treatment  would  at  most  go  only  half-way  toward  cure.  If  a 
diphtheric  septicemia  is  to  be  treated  the  specific  antitoxin  is 
ideal,  unless  too  great  advances  are  made  before  using  it.  In  case 
of  streptococcic  septicemia  the  results  are  less  happy,  owing  to  the 
great  number  of  varieties  of  these  micro-organisms  and  to  the 
practical  worthlessness  of  a  serum  adapted  against  one  variety 
in  the  treatment  of  another.  Antistreptococcic  serum  should 
always  be  used  in  streptococcic  infections,  but  it  cannot  be  used 


SEPSIS  175 

with  the  same  assurance  as  if  one  knew  the  variety  both  of  the 
infection  and  of  the  serum.  The  serum  should  be  used  at  the 
earliest  possible  opportunity,  and  should  be  repeated  daily  or  twice 
daily,  giving  from  10  to  15  c.c.  at  each  sitting,  or  in  larger  doses 
at  wider  intervals,  depending  upon  the  results  obtained. 

If  the  cause  (bacterium)  is  recognized,  it  is  well,  especially  in  the 
chronic  cases,  to  administer  specific  vaccines;  if  it  is  impossible 
or  impracticable  to  determine  the  cause,  autogenous  or  poly- 
valent vaccines  are  to  be  tried. 

Direct  Transfusion  and  Antiseptics,  General  Treatment. — Direct 
transfusion  of  blood  should  be  resorted  to  in  the  subacute  and 
chronic  cases,  but  can  offer  little  hope  in  violent  acute  septicemia, 
as,  indeed,  all  remedies  do. 

Very  naturally,  the  direct  injection  of  antiseptic  solutions  into 
the  general  circulation  suggests  itself  as  a  rational  treatment  of 
septicemia,  and  experimental  and  practical  work  has  been  done 
along  this  line,  but  with  such  varying  reported  results  that  one  can 
scarcely  estimate  the  true  value,  except  to  state  that  it  is  far  below 
the  hope  created  by  the  suggestion. 

Collargol,  10  c.c.  of  a  2  per  cent,  solution,  nitrate  of  silver, 
1  to  \\  grains  in  a  pint  of  water,  and  a  maximum  50  c.c.  of  1 :  2000 
solution  of  formaldehyd,  while  occasionally  giving  apparently  bril- 
liant results,  do  not  prove  of  value  in  more  than  a  small  percentage 
of  cases,  and,  while  their  use  may  be  recommended,  they  do  not 
offer  a  vejy  sanguine  prospect  of  cure. 

PYEMIA1 

Pyemia  is  a  general  septic  condition  characterized  by  the 
presence  of  metastatic  abscesses. 

Cause. — While  certain  non-pyogenic  bacteria  may  exceptionally 
1  ••  i  •  sponsible  for  septicemia,  the  causative  bacteria  of  pyemia  must 
obviously  be  pyogenic.  And  of  these  pyogenic  organisms  the  chief 
OIK •-  inu-1  lie  named  as  streptococci  and  staphylococci.  There 
is,  aside  from  the  pyogenic  qualities  of  all  bacteria  causing  pye- 
mia. no  difference  between  the  etiology  of  septicemia  and  pyemia, 
and  cases  are  seen  in  which  the  first  period  of  illness  is  clinically  a 
septicemia,  and  suddenly,  without  invasion  of  additional  bacteria, 
the  picture  changes  to  that  of  typical  pyemia. 

Pathology. — Since  any  case  of  septicemia  may  become  one 
of  pyemia,  the  same  statements  obtain  here  that  were  made  in 
discu>sinn  the  local  condition  in  the  former  type.  The  primary 
le-i<>n  is  a  gross  lesion,  and  will  usually  be  discoverable  if  searched 
for. 

1  The  so-r:tllni  sept ir<ipyrini:i  differs  in  no  essential  respect  from  pyemia. 


176  PRINCIPLES   OF   SURGERY 

The  general  pathologic  changes  are  the  same  in  pyemia  as  in 
septicemia.  Bacteria  may  be  present  in  the  blood  and  are  de- 
posited from  the  blood;  it  is  immaterial.  But  abscesses  form  in  the 
former  condition,  and  determine  the  essential  difference  between 
the  two  types  of  sepsis.  These  abscesses  are  not  all  of  the  same 
age,  but,  while  one  has  matured,  ruptured,  and  is  healing  nicely, 
others  of  all  grades  of  development  are  to  be  seen.  This,  of  neces- 
sity, depends  on  whether  the  emboli  all  lodged  at  about  the  same 
time  or  continued  to  enter  the  blood  and  lodged  at  intervals  of 
some  days. 

Symptoms. — The  necessary  time  intervening  between  the  date 
of  local  infection  and  the  development  of  pyemia  is  longer  than  in 
either  of  the  preceding  types.  Here  the  local  infection  must  oc- 
cur and  advance  sufficiently  far  to  produce  suppuration  or  dis- 
integrating thrombi,  although  pyemia  occasionally  develops  before 
local  suppuration  occurs,  and  when  the  emboli  enter  the  circulation 
and  lodge  they  must  have  sufficient  time  to  cause  inflammation 
and  abscess  formation.  Hence,  from  the  date  of  the  local  infection 
to  the  manifestation  of  pyemic  symptoms  would  be  several  days, 
from  five  to  seven,  as  a  rule,  or  at  any  subsequent  time. 

The  beginning  of  pyemia  will  show  some  discomfort  and  mal- 
aise, with  a  slight  rise  of  temperature.  This  is  a  kind  of  prodromal 
stage  which  will  often  escape  notice;  even  if  observed  it  could  not 
be  called  pyemia.  The  real  beginning  of  pyemia  is  usually  a  chill, 
frequently  a  prolonged  one.  This  is  followed  by  a  rise  of  tempera- 
ture, often  to  very  high  degrees.  The  initial  chill  is  occasionally 
wanting.  The  general  course  of  the  temperature,  chills,  and  sweat- 
ing is  that  of  pus  absorption  in  its  most  intensified  form.  There 
is  no  regularity  of  these  symptoms,  and  this  irregularity  consti- 
tutes the  essential  significance  of  the  pyemic  chart.  Malaria  and 
typhoid  usually  follow  a  definite  course;  pyemia  almost  never; 
no  two  charts  are  alike,  but  nearly  all  of  them  indicate  pyemia. 
The  fever  is  remittent  or  intermittent,  and  the  time  of  occurrence 
of  these  alterations  of  temperature  cannot  be  foretold.  There  is  a 
chill,  a  rise  of  temperature,  which  may  remain  high  for  a  time,  or 
begin  at  once  to  drop  and  soon  reach  normal  or  subnormal.  These 
excursions  may  be  repeated  several  times  a  day,  there  may  be  a 
high  temperature  in  the  morning  and  a  lower  at  evening,  or  vice 
versa.  A  chill  may  occur  every  day  or  every  other  day,  and  the 
course  of  the  disease  simulate  malaria.  Occasionally  it  is  difficult 
to  differentiate  pyemia  from  typhoid.  Sweating  occurs;  the  skin 
may  be  dry  at  the  beginning,  but  when  the  chills  come  the  skin 
is  constantly  moist  and  the  sweat  is  often  colliquative ;  usually 
the  sweats  are  worse  after  the  chill  and  accompany  a  drop  in  the 
temperature. 


SEPSIS  177 

The  pulse  does  not  show  the  same  cardiac  exhaustion  as  in 
se\ -ere  cases  of  septic  infection  or  septic  intoxication  and  sapremia. 
The  pul>e-rate  increases  with  the  rise  of  temperature  and  returns 
to  or  near  normal  as  the  fever  subsides.  The  blood-pressure  is 
likewi-e  not  much  reduced  in  the  beginning.  In  the  violent  acute 
cases,  when  general  exhaustion  comes  on,  the  pulse  becomes  grad- 
ually more  rapid  and  weak,  and  the  arterial  tension  shows  contin- 
ual reduction.  The  same  general  symptoms  of  headache,  hack- 
ache,  pain  in  the  extremities,  malaise,  dry,  coated  tongue,  thirst, 
loss  of  appetite,  nausea  and  vomiting  are  seen  as  in  all  other  severe 
intoxications.  Diarrhea  is  often  present,  and  depends  for  its  origin 
on  the  same  factor  which  produces  it  in  septicemia,  or  on  the  pres- 
ence  of  metastases  in  or  near  the  intestinal  tract.  Diarrhea  nearly 
always  is  present  in  the  late  stages  and  is  very  foul.  Icterus  is 
neither  constant  nor  early,  but  it  may  appear  after  the  red  cells 
are  disintegrated  in  large  numbers  or  after  the  liver  is  sufficiently 
involved  in  the  pathologic  process. 

The  mental  condition  is  less  exaggerated  in  pyemia  than  in 
septicenua.  The  drowsiness,  somnolence,  and  stupor  of  the  latter 
are  not  present  in  pyemia.  Consciousness  remains  to  torture  the 
patient  with  his  serious  plight.  Delirium  may  appear  during  the 
high  elevations  of  temperature.  Later,  when  exhaustion  is  severe, 
and  t  he  poisons  have  long  affected  the  overworked  nervous  system, 
delirium,  stupor,  and  coma  may  succeed  each  other.  Still  one  will 
often  see  cases  of  pyemia  remain  conscious  until  the  very  last 
inoineiits  of  life. 

The  presence  of  endocarditis,  which  here  is  suppurative 
or  ulcerative,  is  observed  in  from  one-fourth  to  one-fifth  of  all 
ca>e-.  u-ually  affecting  the  mitral  valves,  but  occasionally  the 
bicuspid. 

With  all  the  above  symptoms  and  with  the  changes  observed 
in  the  blood,  namely,  increased  leukocyte  and  reduced  red  blood- 
count,  with  or  without  the  presence  of  micro-organisms  in  the 
blood,  the  diagnosis  of  pyemia,  however  suspicious,  remains  to 
•  nlirined  only  by  the  discovery  of  secondary  abscesses.  These 
ah-ressc*  may  he  few  or  many:  they  may  be  superficial  and  easily 
di-« •< -rnihle  or  deep  and  defiant  of  positive  recognition. 

The  location  of  metastatic  abscesses  depends  on  the  site 
affected  hy  the  primary'  lesion.  The  organs  most  frequently  con- 
taining meta-tatic  abscesses  are  the  large  viscera,  thoracic  and 
abdominal.  The  lungs  >tand  at  the  head  of  the  li>t ;  the  venous 
hlnod  from  the  general  circulation  passes  the  first  set  of  capilla- 
rie-  here.  The  liver  -lands  next:  the  portal  hlood  passes  through 
a  capillary  circulation  in  this  organ.  The  abscesses  may  be  con- 
fined largely  to  one  organ  or  pair  of  organs,  or  they  may  he  dis- 
li 


178  PRINCIPLES   OF   SURGERY 

tributed  ad  libitum,  affecting  every  structure  from  skin  through  to 
mucous  membrane.  Metastases  in  the  brain  are  rare.  A  few 
large  abscesses  may  be  found  or  multitudes  of  small  ones,  or  they 
may  vary  through  all  sizes. 

The  presence  of  metastatic  abscess  in  cases  suspected  of  pyemia 
should  be  sought  for  with  diligence,  only  repeated  complete  phys- 
ical examinations  sufficing;  for,  while  in  one  structure  they  cause 
marked  symptoms  and  in  another  none,  in  a  third  they  var^',  now 
showing  evidence  of  their  presence,  again  showing  none.  When 
abscesses  attack  the  lungs  the  fact  is  perhaps  indicated  by  respira- 
tory disturbances  and  physical  signs,  such  as  consolidation  from 
pneumonia  gives.  Multiple  abscesses  give  clinical  signs  resembling 
catarrhal  pneumonia.  If  the  abscess  is  situated  close  to  the  pleura, 
evidence  of  pleuritis  is  found,  and  there  is  danger  of  rupture  into 
the  pleural  cavity  and  causation  of  pyothorax;  or,  if  near  a 
bronchus,  rupture  causes  expectoration  of  pus,  which  is  often 
malodorous.  Rupture  may  occur  into  bronchus  and  pleural  cav- 
ity at  the  same  time,  and  cause  a  sudden  pneumothorax,  which 
produces  alarming  symptoms  and  later  pyopneumothorax. 

When  the  liver  is  affected,  diagnosis  cannot  be  made  early,  and, 
if  the  abscesses  are  situated  deeply,  they  may  continue  undiscov- 
ered. The  occurrence  of  diarrhea  and  the  appearance  of  pus  or 
pus  and  blood  in  the  stools  points  to  intestinal  involvement.  The 
spleen,  already  enlarged  in  the  course  of  the  disease,  though  not 
frequently  attacked,  offers  great  difficulty  in  diagnosis  if  abscess 
occurs.  Involvement  of  the  kidneys  may  occur  without  evidence, 
or  an  acute  nephritis  may  be  present,  with  clinical  and  urinary 
evidence.  The  osseous  system,  the  joints,  and  the  soft  structures 
offer  fewer  difficulties,  and  show  evidence  of  acute  inflammatory 
involvement  or  of  suppuration. 

Prognosis. — The  acute  cases  of  pyemia  run  a  rapidly  fatal 
course,  and  are,  practically  without  exception,  uninfluenced  by 
treatment.  Chronic  pyemia  lingers  long,  often  being  protracted 
for  months,  and  a  few  cases  of  this  type  end  in  recovery. 

Treatment. — Pyemia  is  to  be  treated  along  the  same  lines  as 
septicemia.  The  only  additional  item  is  the  abscesses  that  come 
up  during  the  progress  of  the  disease.  They  must  be  watched  for 
and  all  suspicious  symptoms  investigated  thoroughly.  As  the 
abscesses  develop  they  are  treated  according  to  the  plan  already 
given. 


CHAPTER  VII 
GANGRENE 

GANGRENE  is  the  death  of  macroscopic  portions  of  tissue  or 
"the  death  of  tissue  en  masse." 

There  are  several  synonyms.  Mortification  is  practically 
identical  with  gangrene,  but  is  also  used  to  signify  the  decomposi- 
tion of  tissue  occurring  at  death.  Necrosis  is  death  of  bone  tissue, 
ami  -ometimes  refers  to  death  of  a  viscus  or  a  portion  of  a  viscus. 
Mummification  is  dry  gangrene.  Sphacelus  is  gangrene  and  putre- 
fact  ion  of  an  extremity.  It  further  means  the  gangrenous  mass  of 
tiBBue. 

The  Etiology  of  Gangrene. — All  cases  of  gangrene  may  be 
attributed  to  one  of  two  fundamental  causes — viz.,  inability  of 
the  tissues  to  give  a  sufficient  supply  of  nutriment,  or  their  inability 
to  ;i— imilate  nutrition  when  it  is  brought  to  them,  or  to  a  com- 
bination of  the  two.  In  the  former  instance  the  cause  is  circu- 
latory, and  may  be  applied  at  the  site  of  gangrene  or  more  or  less 
remote  from  it.  In  the  latter  it  is  due  to  devitalization  of  the 
cells.  >o  that  they  are  killed  at  once  or  so  crippled  that  they  cannot 
maintain  their  existence.  It  is  self-evident  that  in  injuries  sufficient 
to  devitalize  the  tissues  completely  or  incompletely  the  local  vas- 
cular supply  will  be  more  or  less  crippled.  This  fact  needs  to  be 
made  clear,  namely,  that  an  injury  to  the  tissues  may  occur  without 
^.ini:rene,  or  a  crippled  circulation  may  exist  a  long  time  without 
it-  i levelopment ;  but  in  either  instance  coincidence  of  the  other 
factor  cannot  be  withstood.  So  that  either  of  these  conditions 
may  serve  as  a  predisposing  and  the  other  as  the  exciting  cause. 
A  crippled  tissue  may  continue  to  live  on  a  full  blood-supply; 
healthy  ti»ues  may  continue  to  live  on  a  crippled  blood-supply; 
\<\\\  > 'it her  condition,  complicated  by  the  other,  may  immediately 
cau>e  gangrene.  The  importance  of  these  two  items  will  be  seen 
in  prophylactic  treatment. 

/ mult  t/uate  Blood-supply. — Complete  interruption  of  the  cir- 
culation through  a  part  for  a  short  while  (often  in  a  few  hours)  is 
certain  to  produce  ^an^rene.  Further,  when  the  blood-supply  to 
the  part  is  diminished  below  the  minimum  required  to  maintain 
vitality  gangrene  mu-t  result,  but  slowly,  the  rate  of  development 
I't-iim  in  direct  ratio  to  the  reduction  of  circulation.  This  inter- 
ference with  the  circulation  may  occur  either  in  the  arteries  or  the 

179 


180  PRINCIPLES   OF   SURGERY 

veins,  and  may  be  sudden  or  slow  and  complete  or  incomplete. 
The  predisposing  causes  of  gangrene  are  particularly  those  condi- 
tions that  reduce  the  efficiency  of  the  general  circulation  and  reduce 
the  vital  activity  of  the  cells ;  an  illustration  of  the  former  is  poorly 
compensating  heart  lesions,  and  of  the  latter,  diabetes  mellitus. 

To  illustrate  the  importance  of  circulatory  obstruction  in 
gangrene  a  few  of  the  more  usual  disturbances  are  given.  A  very 
frequent  interference  with  nature's  delivery  of  sufficient  quantities 
of  blood  to  the  tissues  is  found  in  arteriosclerosis,  which  narrows 
the  lumen  and  reduces  the  elasticity  of  the  vessels.  Embolism  and 
thrombosis,  the  former  in  arteries,  the  latter  in  veins,  are  quite 
often  responsible  for  gangrene.  Ligation  of  the  main  artery  or 
vein  of  a  part  when  an  insufficient  collateral  circulation  can  be 
established,  or  when  the  collateral  vessels  have  been  injured  by 
undue  trauma  to  the  tissues,  cause  it.  An  occasional  example  is 
seen  in  gangrene  in  the  base  of  the  bladder  where  a  radical  hyster- 
ectomy for  malignancy  has  been  done.  Then,  too,  obstruction 
afforded  by  extravascular  lesions,  as  tumors,  cysts,  and  inflamma- 
tory products,  finally  by  vascular  spasm,  whether  due  to  patho- 
logic or  to  therapeutic  causes.  In  all  conditions,  as  in  various 
forms  of  hernia  and  in  torsion  of  the  viscera,  the  circulation  may  be 
stopped  by  a  constriction  ring  or  by  the  twisted  pedicle,  and  either 
the  venous  circulation  may  be  cut  off  alone  or  in  conjunction  with 
the  arterial.  In  cases  where  these  conditions  are  per  se  incapable 
of  producing  gangrene,  the  reduced  blood-flow  serves  as  a  powerful 
predisposing  cause  when  local  causes  are  added.  An  illustration 
will  elucidate  this.  Suppose  a  case  of  strangulated  hernia.  The 
vital  support  is  almost  entirely  cut  off;  trauma  is  added  by  violent 
efforts  at  reduction,  and  infection  is  added  from  the  lumen  of  the 
gut,  causing  gangrene. 

The  local  causes  of  gangrene  cannot  act  on  the  tissues  ex- 
tensively without  involving  the  local  circulation,  and  so  circula- 
tory obstruction  is  almost  invariably  associated  with  cell  destruc- 
tion. In  this  way  a  smaller  danger  will  result  in  gangrene  if  the 
small  blood-vessels  could  be  spared.  These  local  causes  are  the 
same  as  those  mentioned  under  the  etiology  of  inflammation  as  excit- 
ing causes,  with  possibly  the  exception  of  electricity.  In  the  in- 
flammatory processes  the  causes  were  applied  with  sufficient  inten- 
sity or  duration  to  call  forth  a  defensive  reaction  of  the  tissues,  but 
in  gangrene  the  tissues  are  so  crippled  that  they  cannot  react  or  can 
react  only  inefficiently,  or  they  are  killed  outright  or  partially  by  the 
particular  injury  done.  Heat,  cold,  chemicals,  especially  the  escha- 
rotic  drugs,  traumatism,  and  infection  may  independently  cause  gan- 
grene. It  is  manifest  that  the  first  four  will  cause  a  localized  gan- 
grenous process  unless  there  are  local  or  predisposing  causes  to 


GANGRENE  181 

favor  spreading  gangrene.  Infection  may  cause  a  gangrene  co- 
extensive  with  or  less  than  the  extent  of  the  infected  area;  it  often 
cau-es  a  spreading  gangrene,  and,  when  combined  with  one  of  the 
other  causes  of  this  group,  particularly  trauma,  as  is  usually  the 
case,  it  is  capable  of  producing  rapid  and  extensive  gangrene  al- 
um -t  before  the  surgeon  has  suspected  its  presence. 

Dry  and  Moist  Gangrene. — Before  taking  up  a  study  of  the 
variou-  types  of  gangrene  a  fundamental  clinical  division  of  the 
condition  into  two  types  must  be  noticed,  namely,  dry  gangrene 
a  lit  I  moist  gangrene.  The  essential  difference  between  the  two 
conditions  is  that  in  dry  gangrene  circumstances  have  favored  the 
evaporation  or  absorption  of  fluids  from  the  tissues,  and  perhaps 
at  the  beginning  prevented  engorgement  of  the  vessels  with  blood 
and  the  tissues  with  edema;  while  in  moist  gangrene  circumstances 
have  produced  an  effect  exactly  opposite.  In  other  and  plainer 
words,  a  gangrene  that  develops  slowly  enough  for  the  tissues  to 
( Iry  ( >ut  meanwhile  is  dry ;  rapid  gangrene  is  always  moist.  Sudden 
and  complete  blocking  of  the  arterial  supply  or  blockage  of  the 
venous  return,  whether  complete  or  partial,  causes  moist  gangrene; 
incomplete  blockage  of  the  arteries  causes  dry  gangrene;  infective 
gangrene  is  always  moist.  The  time  required  determines,  more 
than  any  other  factor,  whether  the  gangrene  is  dry  or  moist.  It  is, 
of  course,  unnecessary  to  state  that  internal  gangrenous  or  necrotic 
ti--ue-  are  never  dry;  there  is  no  possibility  of  evaporation. 

The  appearance  of  dry  gangrene  is  characteristic.  The  tissues 
arc  shriveled  and  shrunken.  The  part  is  much  smaller  than  nor- 
mal and  is  cold.  The  gangrenous  mass  is  spoken  of  as  mummified. 
The  cutaneous  surface  has  a  brown,  black,  or  yellowish  color,  and  is 
often  likened  to  the  rind  of  smoked  bacon.  There  are  no  blebs,  no 
Mi-tens,  and  if  they  were  present  at  the  beginning  they  disappear; 
infection  cannot  attack  the  dry,  hard  tissues  except  where  a  line  of 
demarcation  admits  infection  between  the  living  and  the  dead  tis- 
-u e-;  consequently  there  is  little  or  no  malodor  in  dry  gangrene. 
Dry  gangrene  occurs  with  far  the  greatest  frequency  in  the  old, 
in  whom  arterio-clcro-i-  i-  pre-cnt,  whatever  the  cause  of  it,  with 
an  ever-increa-ing  gradual  reduction  in  the  blood-carrying  capacity 
of  the  arteries,  and  an  undiminished  opportunity  for  the  escape  of 
the  Mood  through  the  veins  whose  caliber  has  not  been  altered. 
It  occur-  where  an  embolus  partially  blocks  the  main  artery,  and 
where  a  prolonged  and  incomplete  angiospasm  is  produced  by  the 
long-continued  use  of  ergot  and  in  Raynaud's  disease.  Gangrene 
resulting  from  severe  burns  and  from  frost-bites  is  frequently  dry, 
and  dialectic  gangrene  may  l>e  dry.  Cangrene  of  the  finger-tips, 
ear-,  and  toe-  is  usually  dry  when  it  i<  confine  1  to  the-e  structures. 

M"i-t  gangrene  presents  different  phenomena.     Here  the  tis- 


182 


PRINCIPLES   OF   SURGERY 


sues  are  swollen,  they  are  larger  than  normal,  and  blebs  appear 
beneath  the  cuticle  and  are  filled  with  a  serous  fluid;  it  is  often 


Fig.  29. — Moist  gangrene  from  frost-bite. 

sanious.      These  blebs  may  be  moved  from  place  to  place  by  pres- 
sure, and  gravitate  to  the  lowest  level  hi  any  position,  a  distinction 


Fig.  30. — Moist  gangrene.     Senile. 

from  the  blebs  found  hi  burns.  The  tissues  are  edematous  and 
boggy;  they  contain  an  excess  of  fluid.  The  cuticle  is  easily 
stripped  off,  and  thus  an  atrium  of  infection  is  afforded.  The  color 


GANGRENE  183 

varie-  i-vt-ii  in  the  same  case;  the  color  at  the  beginning  is  bluish  or 
purplish-mi,  and,  as  the  condition  advances,  the  color  becomes 
brown,  black,  or  mottled;  other  colors  are  noted  occasionally,  as  is 
illu-t rated  by  the  greenish  appearance  resulting  when  hydrogen 
-ulphid  is  liberated  in  the  decomposition  of  the  parts.  The  odor 
i-  foul,  and  is  the  same  as  that  of  postmortem  decomposition;  if 
ii<>  infection  is  present,  which  is  a  rare  exception,  there  will  be  no 
malodor.  The  odor  is  due  to  the  formation  of  sulphuretted  hydro- 
gen, butyric  and  valerianic  acids,  ammonia  and  skatol,  besides 
many  other  unpleasant  compounds.  When  one  imagines  a  combi- 
nation of  the  above  list  of  foul-smelling  products  it  becomes  super- 
fluous to  comment  further  on  the  odor.  Gases  may  accumulate  in 
tin-  gangrenous  and  even  adjacent  tissues  as  a  result  of  gasogenic 
infection.  Then  crepitation  becomes  an  important  and  ominous 


Fin.  31. — Gangrenous  appendix  fifti-cn  hours  after  first  attack. 

>ign.  A-  the  process  continues  decomposition  advances,  and  the 
part-  are  -o  completely  changed  that  they  drop  away  of  their  own 

weight. 

Tain  as  a  symptom  in  gangrene  is  very  variable.     It  may  be 
:it  from  the  Beginning  and  remain,  being  kept  up  by  the  ad- 
vance of   the   process  on  to  living   tissue.     In  cases  of  limited 

gangrene  the  p;iin  ceases  when  the  ti— ues  die,  but,  as  long  as  they 
live  ami  are  feeling  the  need  of  un-upplied  nourishment  or  the  irri- 
tation of  deadly  poison-,  the  pain  i-inten-e.  In  gangrene  due  to 
emliolus  the  pain  i>  felt  in  the  whole  of  the  region  deprived  of  blood 
and  is  often  violent.  Pain  from  this  source  may  be  referred,  just 
;i-  in  other  condition-. 

An  important  precaution  is  to  lie  pointed  out  here;  in  all  those 
condition-,  obstructive  or  inflammatory,  where  gangrene  is  capa- 
ble of  developing,  a-  in  appendicitis,  cholecystitis  and  strangulated 


184  PRINCIPLES   OF   SURGERY 

hernia,  and  intestinal  obstruction  generally,  in  which,  from  the 
patient's  view-point,  the  pain  is  the  most  important  symptom, 
and  where  cessation  of  the  pain  in  a  brief  time  without  anodynes 
would  mean  that  the  part  has  become  gangrenous,  the  administra- 
tion of  anodynes,  accompanied  with  non-surgical  treatment,  should 
be  recognized  as  a  most  injudicious  and  dangerous  practice.  How- 
ever much  surgery  may  have  been  indicated  before  such  sudden 
cessation  of  the  pain,  it  is  absolute  and  imperative  afterward,  and 
this  indication  will  be  lost  if  the  one  most  important  symptom  is 
eliminated  by  a  dose  of  morphin. 

Line  of  Demarcation. — There  is  frequently  a  definite  line  mark- 
ing the  border  between  the  living  and  the  gangrenous  parts.  It  is 
known  as  the  line  of  demarcation.  It  is  rarely  a  regular,  even  line, 
but  is  uneven,  reaching  higher  levels  on  one  aspect  than  on  another, 
and  may  be  broken,  extending,  for  example,  only  partially  around 
an  extremity.  It  marks  the  level  at  which  the  tissues  are  able  to 
withstand  the  gangrenous  process,  at  which  the  blood-supply 
is  able  to  take  care  of  the  cells,  or  the  cells  able  to  maintain  them- 
selves; at  which  separation  of  the  living  from  the  dead  tissue  will 
take  place,  if  at  all.  On  one  side  of  this  line  the  tissues  were  not 
sufficiently  crippled  to  lose  their  vitality,  on  the  other  they  were  too 
badly  crippled  to  maintain  it.  It  is  at  this  level  that  self-amputa- 
tion occurs,  if  at  all.  At  the  line  of  demarcation,  when  separation 
occurs,  there  is  usually  a  purulent  or  seropurulent  discharge,  and 
the  living  tissues  immediately  above  the  line  of  demarcation  show 
an  inflammatory  reaction  due  to  the  bacteria  that  have  gained 
admission. 

General  Symptoms. — Gangrene  may  exist  without  the  presence 
of  constitutional  symptoms,  or  they  may  be  present  in  all  grada- 
tions, from  the  mildest  to  the  most  violent;  the  symptoms  are  of  the 
sapremic  type.  In  cases  where  the  gangrene  is  caused  or  predis- 
posed to  by  a  constitutional  disease  the  symptoms  of  the  former 
are  superadded  to  those  of  the  latter.  The  general  symptoms  are 
least  marked  in  dry  gangrene,  more  marked  in  moist  gangrene,  and 
most  intense  when  the  latter  is  caused  by  infection.  On  the  other 
hand,  mild  constitutional  symptoms  are  sometimes  observed  in 
gangrenous  conditions  which  are  not  infected. 

Senile  Gangrene. — This  term  is  applied  to  gangrene  caused  by 
senile  changes  in  the  arteries,  namely,  arteriosclerosis  and  athe- 
roma.  However,  the  conclusion  must  not  be  drawn  that  a  certain 
age  must  be  reached  before  senile  gangrene  may  develop;  for, 
although  this  type  of  gangrene  is  usually  seen  in  individuals  past 
fifty  years,  arteriosclerotic  changes  may  develop  in  compara- 
tively young  individuals  and  favor  its  appearance. in  them. 

Admitting   the   presence   of   arteriosclerosis    and   the    conse- 


GANGRENE  185 

quent  prolonged  and  gradually  increasing  malnutrition  of  the 
ti--uev.  the  appearance  of  senile  gangrene  is  usually  attributed  by 
tin-  patient  to  trauma,  which,  under  ordinary  circumstances, 
would  lie  in.-iunificant,  such  as  a  slight  bruise,  the  pinching  of  a 
toe  1  >v  t  he  shoe,  an  ingrowing  nail,  trimming  a  corn,  or  a  hang-nail. 
Diminished  heart  action  is  very  favorable.  Thrombosis  of  the 
small  blood-vessels  or  embolism  of  the  arteries  are  additional 


I  it  lile  gangrene  in  little  toe  and  just  beginning  in  the  fourth 

t<M-.  Thi-  patient's  other  leg  had  been  previously  amputated  for  the  same 
condition. 

cau-es.  I'ain  may  be  very  severe  or  insignificant.  One  sees  cases 
of  gradually  extending  senile  gangrene  without  apparent  evidence 
of  discomfort.  The  slight  injury  that  serves  as  the  starting-point 
of  the  nannrene  i-  usually  extraordinarily  painful.  Senile  gangrene 
is  u-ually  dry.lmt  it  is  occasionally  moi>t :  it  is  usually  seen  affect  inir 
the  lower  extremity,  l.e^inninn  in  one  or  more  toes;  it  is  rarely  seen 
in  the  upper  extremity.  The  presence  of  pain  in  a  toe.  with  no 
adequate  explanation,  in  an  individual  of  advanced  age  who  has 


186  PRINCIPLES   OF   SURGERY 

hard  arteries,  should  not  lead  one  to  make  a  diagnosis  of  gout, 
as  is  often  done,  for  a  little  care  will  clear  up  the  matter,  as  when 
the  characteristic  discoloration,  purplish  or  bluish,  appears  at  the 
painful  spot  the  real  cause  may  be  decided  upon.  As  soon  as  the 
tissues  necrose  the  pain  ceases  and  the  general  comfort  remains 
undisturbed,  provided  the  process  is  not  advancing.  The  advance 
of  the  gangrene  may  be  checked  by  a  line  of  demarcation  at  the  met- 
atarsophalangeal  articulation,  and  the  toes  become  dry  and  black 
and  hard;  or  the  tissues  may  be  unable  to  resist  the  advance,  and 
the  gangrene  gradually  extend  on  the  foot  and  to  other  toes.  The 
outlook  is  much  less  hopeful  when  self-limitation  has  failed  to  occur 
at  the  base  of  the  toes.  If  infection  gains  admission,  as  is  fre- 
quently the  case,  the  living  tissues  adjacent  to  the  border  become 
inflamed,  and  this  reduces  the  efforts  at  demarcation  and  favors 
a  further  and  more  rapid  extension.  Occasionally  the  gangrene, 
extends  well  up  the  leg,  but,  as  a  rule,  these  patients  die  of  sepsis 
or  exhaustion  before  the  leg  is  materially  involved.  Extensive 
crippling  of  the  large  vessels  of  the  leg  favors  extension  of  the  gan- 
grene to  the  leg. 

More  rapidly  developing  cases  of  senile  gangrene  are  those  due 
to  the  lodgment  of  emboli  at  the  bifurcation  of  the  popliteal  artery 
and  those  hi  which  thrombosis  of  the  main  vessels  of  the  leg  occurs. 
In  such  cases  the  pain  is  more  extensive,  often  violent,  and,  in  case 
of  embolism,  very  sudden.  The  primary  appearance  of  discolora- 
tion is  of  wider  extent  and  the  extremity  becomes  cold.  The 
pulse  is  absent  from  the  vessels  of  the  affected  part.  The  gangrene 
extends  from  the  parts  receiving  no  collateral  circulation  upward 
until  a  level  is  reached  which  has  an  adequate  blood-supply.  If 
thrombosis  affects  the  femoral  vessels,  there  is  no  limit  to  the 
advancing  gangrene  and  the  prognosis  becomes  hopeless. 

Spreading  Traumatic  Gangrene,  Fulminating  Gangrene,  Gan- 
grene Foudroyante,  Gangrenous  Emphysema,  Microbic  Gan- 
grene.— The  behavior  of  these  gangrenous  processes  is  so  similar 
that  they  may  all  be  treated  under  one  heading.  They  are  all 
caused  by  bacteria;  they  are  usually  preceded  by  a  more  or  less 
severe  injury.  The  injury  may  per  se  cause  a  definite  extent  of 
gangrene;  the  spread  is  invariably  due  to  the  bacteria. 

Spreading  traumatic  gangrene  is  seen  usually  following 
severe  contused  and  lacerated  wounds  and  compound  fractures 
which  have  been  infected  at  the  time  of  injury.  The  infection 
begins  at  the  atrium  and  spreads  rapidly,  causing  thrombosis  of 
the  veins  and  necrosis  of  the  tissues.  Gas  may  be  produced,  and 
when  it  is,  recognition  of  its  presence  is  made  by  the  discovery  of 
crepitus,  which  is  interpreted  as  meaning  that  the  infection  has 
spread  to  that  level. 


GANGRENE  187 

The  surface  of  the  wound  may  appear  perfectly  normal,  and 
even  when  tin-  >kiu  is  involved  the  extent  of  this  involvement  can- 
not he  accepted  as  the  measure  of  gangrene  of  subcutaneous 
struct ures,  and,  therefore,  is  a  worthless  index  as  to  the  point  at 
which  removal  must  be  done.  The  first  evidence  of  this  type  of 
gangrene  is  that  the  infection  causes  a  rise  of  temperature,  or  it 
may  l»c  the  discharge  of  a  foul-smelling  fluid,  serous  or  sanio- 
>en>us.  from  the  wound;  the  escape  of  such  fluid  should  lead  to  a 
thorough  investigation  without  delay  regardless  of  surface  appear- 
•noee. 

The  constitutional  symptoms  are  those  of  an  intense  infection 
;m<l  belong  to  the  sapremic  type  (q.  v.).  The  violence  of  the  symp- 
tom- may  be  understood  from  the  fact  that  it  is  the  most  rapidly 
fatal  type  of  gangrene  known;  death  may  come  in  four  or  five  days 
from  the  date  of  infection. 

The  presence  of  emphysema  only  adds  to  the  gravity  of  the 
condition,  as  the  tissues  are  loosened  by  the  gas-bubbles  and  an 
•  •asy  spread  of  the  infection  thereby  becomes  possible. 

The  prognosis  is  always  grave  and,  unless  the  most  active 
treatment  is  instituted  early,  it  is  certain  to  terminate  fatally. 

Diabetic  Gangrene. — Diabetic  gangrene  is  observed  coming 
up  in  the  course  of  diabetes  mellitus.  Frequently  the  gangrene 
directs  attention  to  it.  The  cause  of  it  is  found  in  the  general  loss 
of  vitality  of  the  tissues  in  such  cases,  but  the  fact  that  arterio- 
>clerosi>  of  the  vessel  supplying  the  gangrenous  region  is  found  in 
tin  i  Majority  of  cases  has  caused  many  pathologists  to  consider  this 
the  chief  cause;  some  consider  it  the  only  cause.  There  can  be  no 
doubt,  however,  that  diabetes  of  itself  favors  the  occurrence  of 
ene.  Diabetic  gangrene  may  originate  without  apparent 
outside  provocation,  but,  as  in  other  types,  the  occurrence  of  a 
>light  injury  in  favorable  subjects  often  serves  as  a  starting- 
point,  (langrene  usually  begins  in  the  little  or  big  toe,  and  the 
majority  of  cases  affect  the  lower  extremity.  Occasionally  other 
parts  of  the  body  are  affected,  as  the  buttocks,  hands,  face,  neck, 
or  external  genitals.  The  lungs  are  rarely  affected.  Diabetic 
gangrene  may  appear  in  a  single  primary  focus,  or  there  may  be 
multiple  foci  appearing  at  about  the  same  time,  followed  subse- 
quently by  other  gangrenous  areas,  until  the  lower  extremities  are 
mottled  with  dark  patches.  It  is  dry  or  moist,  and,  so  far  as  the 
appearance  of  the  gangrene  and  its  clinical  behavior  is  concerned, 
cannot  be  di-t ingui-hed  from  other  types  until  the  recognition  of 
the  cau-ative  constitutional  disease  determines  its  nature.  A  line 
of  demarcation  may  form,  but  the  poor  vitality  of  the  ti-sue-  to- 
gether with  the  reduced  hlood->upply  may  be  so  marked  that  no 
line  will  form. 


188  PRINCIPLES   OF   SURGERY 

Diabetic  patients  are  always  poor  surgical  risks,  and  only  the 
most  serious  and  urgent  demands  justify  surgical  treatment,  major 
or  minor.  The  additional  presence  of  arteriosclerosis  demands 
even  further  precaution,  for  instead  of  nprmal  healing  gangrene 
may  develop.  After  removal  of  the  gangrenous  part  one  can  only 
hope  that  the  process  will  not  be  re-established  at  the  line  of  in- 
cision, even  when  this  is  made  remote  from  the  original  gan- 
grenous area.  It  is  claimed  that  removal  of  the  gangrenous  tis- 
sue causes  a  temporary  reduction  in  the  output  of  sugar. 

Prognosis. — The  prognosis  of  diabetic  gangrene  is  extremely  bad. 

Symmetric  Gangrene,  Raynaud's  Gangrene. — Raynaud's  dis- 
ease is  a  condition  which  depends  for  its  cause  upon  some  central 
or  reflex  disturbance  of  the  vasomotor  nerves,  which  causes  pro- 
longed symmetric  angiospasm.  The  arterial  contraction  has 
been  demonstrated  in  the  retina  of  a  patient  who  had  a  concomi- 
tant disturbance  of  vision.  The  parts  affected  are  usually  fingers 
or  toes,  but  the  cheeks,  nose,  buttocks,  and  other  regions  may  be 
affected.  The  condition  is  found  in  women  in  80  per  cent,  of  the 
cases,  and  these  are  usually  between  the  age  of  eighteen  and  thirty 
years.  Exposure  to  cold  is  usually  the  exciting  cause,  although 
it  appears  at  seasons  of  the  year  and  under  circumstances  such  as 
to  eliminate  this  element  practically  from  the  etiology.  Ray- 
naud's disease  may  be  acute  or  chronic,  and  is  seen  more  often 
in  thin,  poorly  nourished,  nervous  individuals.  Similar  conditions 
occur  rarely  in  the  course  of  such  affections  as  syringomyelia, 
multiple  sclerosis,  tabes,  and  tumors  of  the  cord.  There  are  three 
stages  of  the  disease: 

(1)  Local  syncope,  during  which  the  part  becomes  cold  and 
pale,  and  assumes  a  waxy  appearance.     This  stage  may  come  and 
go,  resulting  in  numbness,  pain,  and  stiffness  during  the  attack, 
followed  by  a  return  to  normal.     One  not  infrequently  hears  a 
layman  refer  to  his  "cold  finger"  or  toe,  and  occasionally  sees  the 
condition  in  young  women  subsequent  to  a  cold  bath. 

(2)  Local  asphyxia,  in  which  the  part  becomes  blue  or  cyanotic. 
The  pallor  is  replaced  by  a  bluish  discoloration,  which  disappears 
under  pressure  and  slowly  returns  on  removal  of  the  pressure. 
The  color  may  increase  until  the  part  becomes  almost  or  quite 
black.     Blebs  form  over  the  areas  most  intensely  affected,  and 
later  rupture,  allowing  the  escape  of  a  serous  or  seropurulent  fluid. 
Pain  is  often  intense  during  this  stage,  and  the  condition  either 
begins  to  improve,  the  raw  surfaces  heal,  the  pain  subsides,  and  the 
discoloration  disappears,  leaving  the  finger  withered  and  flattened, 
only  to  recur  again  and  again  for  a  few  years;  or  in  any  attack  it 
may  go  on  to  the  third  stage. 

(3)  Raynaud's,  or  symmetric  gangrene,  in  which  the  cyanotic 


GANGRENE  189 

portion  partially  necroses,  and  becomes  dry  and  hard  and  black; 
tlu  gangrene  usually  affects  the  last  phalanx  of  a  finger  or  toe, 
sometimes  of  several,  and  it  rarely  extends  further  in  a  proximal 
direction  than  the  base  of  the  digits.  The  gangrenous  area  is  not 
coextensive  with  the  cyanotic  area,  and  it  is  impossible  to  say  in  a 
»;iveii  case  what  the  limits  of  the  gangrene  will  be.  Inasmuch  as 
the  disease  is  self-limited,  hasty  removal  of  the  parts  need  not  be 
undertaken.  A  line  of  demarcation  occurs,  and  frequently  self- 
am]  >ut  at  ion  and  subsequent  healing  is  seen. 

Raynaud's  disease  has  been  mistaken  for  gout  on  account  of  the 

pain  affecting  the  toes  and  fingers,  but  observation  of  the  conditions 

nt,  a  correct  history,  and  the  character  of  patients  in  whom  the 

two  conditions  appear  should  prevent  frequent  occurrence  of  this 

error. 

uptowns. — The  constitutional  symptoms  are  negligible. 

Prognosis. — The  prognosis  for  life  is  good,  and,  under  proper 
treatment  and  not  too  hasty  removal  of  the  parts,  is  better  for  the 
structure  affected  than  the  first  appearance  would  indicate. 

Ergot  Gangrene. — This  type  of  gangrene  is  rarely  seen  now-a- 
day-.  I >ut  was  very  frequent  in  the  seventeenth  and  eighteenth 
centurie<.  It  resulted  from  chronic  ergot-poisoning,  produced  by 
eating  bread  made  from  rye.  Rarely  a  case  is  reported  from 
prolonged  administration  of  the  drug  for  therapeutic  purposes. 
It  causes  spasms  of  the  blood-vessels  and  acts  similarly  to  Ray- 
naud'>  disease — the  digits  are  usually  affected,  especially  the  toes, 
hut  the  gangrene  may  involve  a  hand,  foot,  or  whole  extremity. 
The  initial  symptom  is  pain,  then  pallor  of  the  part;  coldness, 
numhness,  or  anesthesia  follows.  Formication  is  often  complained 
of.  If  the  case  is  severe  the  local  changes  may  be  associated  with 
constitutional  symptoms  of  ergotism.  Following  the  stage  of 
pallor  a  dilation  of  the  blood-vessels  occurs,  the  vessels  are  filled 
with  blood,  the  part  becomes  cyanotic,  and  gangrene  supervenes; 
it  i>  dry  or  moist,  dependent  upon  the  rapidity  of  development. 
Kxainination  of  the  gangrenous  part  shows  the  vessels  filled  with 
clotted  blood.  In  the  slower  cases  a  line  of  demarcation  develops 
and  self-amputation  may  follow,  but  in  the  extensive,  rapid  cases 
there  i>  no  line  of  demarcation. 

Hospital  Gangrene. — This  type  of  gangrene  produced  extensive 
ravage-  in  preantiseptic  days,  but  is  so  rare  now  that  few  living 
physician-  perhaps  have  seen  a  sufficient  number  of  cases  to  be  well 
acquainted  with  it.  It  has  occurred  more  especially  in  times  (.f 
war  and  under  had  hygienic  -urroundinns.  such  as  obtain  in  crowded 
hospital  wards.  It  is  of  an  infectious  nature,  but  no  particular 
nricro-organi-ni  is  held  account  a  hie  as  the  causative  agent,  and 
it  i-  prohahly  produced  hv  different  bacteria,  often  in  mixed  cul- 


190  PRINCIPLES   OF   SURGERY 

ture.  When  once  it  gains  entrance  to  a  hospital  ward  it  can  be 
communicated  to  other  patients  by  direct  transmission.  Where 
strict  asepsis  can  be  maintained  other  wounds  are  in  no  danger. 
However,  isolation  is  required,  and  the  nurse  who  attends  this 
disease  must  not  be  permitted  to  make  other  dressings. 

Ordinarily,  granulations  serve  as  a  barrier  to  infection,  but  the 
rule  fails  in  hospital  gangrene,  for  new  wounds,  granulating  wounds, 
and  even  recently  healed  wounds  all  fail  alike  in  withstanding  the 
destructive  advance  of  this  dreadful  condition. 

The  period  of  incubation  is  very  short,  and  varies  from  less  than 
twenty-four  hours  to  a  few  days. 

The  constitutional  symptoms  are  those  of  an  infection.  There 
may  in  severe  cases  be  a  chill — the  temperature  rises,  as  a  rule,  but 
may  remain  normal  or  subnormal.  The  pulse  is  accelerated  and 
the  general  condition  is  worse  than  the  temperature-chart  would 
indicate.  Prostration  is  great  in  severe  cases. 

The  local  condition  is  described  under  three  types:  (1)  The 
croupous  or  diphtheric.  (2)  The  ulcerative.  (3)  The  pulpy. 

(1)  The  diphtheric  type  begins  by  the  appearance  of  necrotic 
spots  on  the  granulating  surface  and  the  formation  of  a  false,  or 
diphtheric,  membrane  over  the  wound,  and  the  disappearance  of 
granulations  and  necrosis  of  tissue  underneath  the  membrane. 
There  is  an  ichorous  discharge  of  limited  quantity,  the  odor  of 
which   is   foul.     The   surrounding   edges   are   slightly   inflamed. 
This  is  the  mildest  type. 

(2)  The  ulcerative  type,  similar  in  appearance  to  the  first  typo, 
is  more  serious,  and  spreads  into  the  surrounding  tissues  in  an  in- 
sidious manner,  often  extending  far  under  the  surrounding  skin. 
The  discharge  is  more  abundant  and  the  constitutional  symptoms 
more  severe.     The  edges  are  clean  cut  and  surrounded  by  an  in- 
flamed zone. 

(3)  The  pulpy  type,  the  most  severe,  causes  a  distinct  gangrene. 
There  appears  a  thick  membrane  of  a  dirty  gray  or  yellow  appear- 
ance.    This  is  at  first  dry.     When  it  is  removed  no  granulations 
are  seen,  but  instead  a  raw,  bleeding  surface.     The  surface  soon 
changes,  and  a  large  quantity  of  foul-smelling  discharge  results. 
The  tissues  are  converted  into  a  bulky,  pulpy,  gelatinous  mass 
which  often  contains  gas,  and  hemorrhages  are  likely  to  occur  and 
recur.     They  are  exceedingly  difficult  to  control,  and  if  from  a  large 
vessel  are  apt  to  terminate  fatally,  for  the  vessel  walls  are  destroyed 
by  necrosis  and  will  not  tolerate  application  of  forceps  or  ligatures. 
The  advance  of  necrosis  is  rapid,  and  no  tissue  is  spared.     The 
surrounding  tissue  is  swollen,  inflamed,  and  edematous.     The  con- 
stitutional   symptoms    are    intense.     Septicemia    is    a    frequent 
complication. 


GANGRENE  191 

In  all  types  of  hospital  gangrene,  when  the  necrotic  tissue 
sloughs  away  or  has  been  removed  and  granulations  cover  the 
surface,  recurrence  may  take  place  at  any  time  prior  to  complete 
healing  of  the  ulcer. 

The  prognosis  of  hospital  gangrene  is  bad;  in  the  worst  epi- 
demic- the  mortality  has  exceeded  80  per  cent. 

Gangrene  Due  to  Infection  by  the  Bacillus  Aerogenes  Capsu- 
latus. — So  many  cases  of  gangrene  due  to  infection  with  Welch's 
bacillus  are  being  reported  in  current  literature  that  it  is  necessary 
to  discuss  it  in  this  connection.  The  close  relationship  existing 
between  this  type  of  gangrene  and  hospital  gangrene  cannot  fail 
to  lie  noted. 

Bacillus  aerogenes  capsulatus,  belonging  to  the  flora  of  the 
human  alimentary  canal,  rarely  produces  infection  because  of  two 
fact-:  (1)  Because  under  ordinary  circumstances  it  is  slightly 
pathogenic,  although  when  transmitted  from  an  infection  of  human 
ti— u<-  it  i-  exceedingly  virulent.  (2)  Because  it  is  an  anaerobe. 

The  period  of  incubation  for  Welch's  bacillus  varies  from  eight 
-  to  seven  or  eight  days.  It  is  usually  between  two  and  six 
The  regions  most  frequently  infected  are  the  perineal  region 
i<l  the  abdomen,  especially  in  connection  with  perforative  perito- 
lit  i- ;  the  subcutaneous  fat  seems  to  offer  an  especially  inviting  field. 

1  personally  observed  cases,  2  were  in  the  subcutaneous  fat  fol- 
lowing operat  ion  for  perforative  appendicitis.  The  local  signs  cannot 
be  distinguished  from  those  of  an  ordinary  inflammation  until  gas 
format  ion  and  crepitus  occurs.  The  appearanpe  of  crepitus  should 
at  once  arouse  suspicion  of  this  bacillus.  It  is  probably  the  cause 
of  the  majority  of  inflammations  associated  with  gas  production. 
The  gas  is  inflammable.  It  may  not  appear,  owing  to  the  presence 
of  a  mixed  infection,  and  here  it  may  be  stated  that  Welch's 
•acillus  is  often  enabled  to  attack  human  tissue  by  virtue  of  the 
ice  of  a  symbiotic  aerobe.  Welch's  bacillus  is  non-pyogenic; 
therefore  the  presence  of  pus  argues  mixed  infection.  It  is  often 
:ateil  with  colon  bacillus,  and  may  lead  to  the  diagnosis  of  fecal 
fi-tula,  owing  to  the  presence  of  gas  and  the  characteristic  odor. 
a  wound  is  infected  with  Bacillus  aerogenes  capsulatus  the 
•ubcutaneoua  ti— ue  first  becomes  necrotic,  and  the  skin  edges  of 
the  wound,  although  apparently  healing  well,  can  be  easily  sepa- 
rateil,  and  the  subcutaneous  fat  is  found  to  be  already  necrotic  and 
grayish  or  yellowish  black,  and.  if  they  are  left  alone  for  a  time, 
it  soon  become-  semigelatinous  and  easily  broken  up.  The  skin 
or  muc.m-  membrane  becomes  involved,  and  the  process  gradually 
s  -paring  no  >tructure.  Consequently,  hemorrhage  is  likely 
to  occur;  if  a  mixed  pyngenic  infection  occurs  the  appearance  is 
that  of  a  phlegmonous  suppuration. 


192  PRINCIPLES   OF   SURGERY 

The  constitutional  symptoms  are  in  no  way  characteristic,  and 
may  be  briefly  comprehended  in  the  statement  that  they  are  such 
as  would  be  produced  by  a  septic  intoxication.  They  may  be  mild 
or  violent,  but  this  variance  cannot  be  considered  a  safe  index  to  the 
prognosis.  There  is  rarely  an  initial  chill,  but  this  is  likely  to 
occur  if  there  is  a  mixed  pyogenic  infection.  The  temperature 
ranges  from  100°  to  104°  F.,  or  with  subnormal  registration  in 
violent  intoxications.  The  patient  is  weak  and  anxious,  the  pulse 
rapid,  small,  and  soft.  The  remaining  symptoms  cannot  be 
distinguished  from  those  of  ordinary  infections. 

The  prognosis  is  unfavorable,  as  the  average  mortality  is  about 
50  per  cent. 

Noma,  Cancrum  Oris,  Cancer  Aquaticus. — This  is  an  infective 
gangrene  occurring  in  the  cheek  and  the  external  female  genitalia. 


Fig.  33. — Noma,  after  separation  of  necrotic  tissue.     Negro  child,  six  years 

of  age. 

It  is  comparatively  rare.  Noma  is  seen  usually  between  the  ages 
of  two  and  twelve  years,  rarely  in  older  individuals.  The  pre- 
disposing cause  is  poor  vitality,  such  as  is  seen  so  often  in  the 
children  of  crowded  tenement  districts  whose  surroundings  are 
entirely  bad.  It  may  follow  the  infectious  diseases,  as  scarlet 
fever,  measles,  typhus,  or  diphtheria.  Occasionally  it  originates 
spontaneously  or  without  the  favorable  action  of  the  above- 
named  predisposing  causes.  The  cause  of  noma  is  an  infection, 
but  no  specific  bacterium  seems  responsible,  various  bacteria  hav- 
ing been  described  by  different  investigators,  such  as  streptothrix, 
spirilla  growing  symbiotic  with  Bacillus  fusiformis,  and  the  bacillus 


GANGRENE  193 

of  diphtheria.  Cases  produced  by  the  latter  have  been  relieved 
by  the  administration  of  antidiphtheric  serum.  It  is  probably 
limn-  accurately  attributed  to  mixed  infection.  Recent  investiga- 
tion- indicate  that  the  most  frequent  if  not  the  sole  cause  is 
Vincent's  Bacillus  fusiformis. 

Local  Appearance. — The  beginning  of  noma  is  an  infiltration 
which  appears  usually  in  an  ulcer  or  blister  on  the  mucous  mem- 
brane near  the  angle  of  the  mouth,  or,  exceptionally,  in  other 
pan-  of  the  mouth.  The  mass  can  be  felt  as  a  lump  in  the  cheek 
and  soon  becomes  gangrenous.  On  the  cutaneous  surface  the  first 
change  is  a  cyanotic  discoloration,  later  becoming  black,  sur- 
rounded by  a  red,  inflammatory  border.  The  cheek  is  otherwise 
pale  and  swollen.  A  bleb  is  sometimes  formed  over  the  necrotic 
ma«.  A  kind  of  pseudoline  of  demaraction  may  form,  and  the 
slough  be  cast  off,  leaving  the  characteristic  perforation  of  the 
cheek.  But  the  line  of  demarcation  here  has  not  its  usual  signifi- 
cance, for  the  gangrenous  process  usually  spreads  rapidly  and 
spares  nothing  in  its  course.  The  bones  of  the  face  are  laid  bare 
and  may  become  necrotic.  The  tongue  usually  escapes.  The 
hideous  picture  of  noma  in  severe  forms  can  scarcely  be  described. 
The  -welling  of  the  face  and  neck,  the  destruction  of  tissue  from 
mouth  to  ear.  from  ear  to  eye,  the  exposure  of  the  naked  bone  in 
the  mid>t  of  the  decomposing  tissues,  the  sight  of  the  mouth  cavity 
and  the  teeth,  from  which  the  gums  and  perhaps  the  bone  have 
been  destroyed,  produces  one  of  the  most  revolting  pictures  of 
pathology.  It  is  unnecessary  to  add  that  the  odor  is  horrible. 

dim  ml  Symptoms. — The  constitutional  symptoms  are  severe 
from  the  beginning.  The  temperature  is  high  and  continuous  and 
the  pul-e  rapid,  small,  and  low  of  tension.  A  chill  may  occur  at  the 
beginning  and  may  be  repeated.  Prostration  is  great,  and  this, 
combined  with  the  elevation  of  temperature,  is  a  good  index  to  the 
progno>i-.  Mental  symptoms  are  especially  marked,  delirium  and 
coma  being  often  present  almost  from  the  beginning  and  remaining 
until  the  end.  When  noma  comes  as  a  complication  of  an  in- 
fectious fever,  the  symptoms  may  not  be  recognizable,  and  appear 
to  1  ic  ( in  1  v  an  exacerbation  of  the  predisposing  disease.  Aspiration- 
pneumonia  is  the  most  frequent  cause  of  death. 

When  the  vulva  is  attacked  by  noma  the  labia  are  usually 
attacked,  and  from  this  point  the  gangrene  spreads  until  it  covers 
the  perineal  region,  and  it  may  extend  to  the  buttocks,  thighs,  or 
mon-  veneri-.  The  same  tendency  to  spare  nothing,  and  to  extend 
deeply  and  aff eel  the  bony  stnictur*  .n  here  as  in  noma  ori-. 

If  the  patient  recovers,  the  awful  deformity  remains  to  lie  relieved, 
u-uallv  only  partially,  by  plastic  work. 

Carbolic  Acid  Gangrene.     The  widely  extensive  favor  of  car- 


194  PRINCIPLES   OF   SURGERY 

bolic  acid  as  an  antiseptic,  and  the  frequent  use  of  the  drug  in  the 
treatment  of  such  conditions  as  acute  abscesses,  bursal  ganglia, 
and  hydrocele  renders  it  important  to  call  attention  to  carbolic 
acid  gangrene.  It  is  perhaps  the  most  frequent  type  of  gangrene 
produced  by  the  local  effect  of  chemicals.  Lysol  sometimes  behaves 
in  the  same  manner. 

When  carbolic  acid  is  applied,  even  in  weak  solution,  and  is 
allowed  to  remain  in  contact  with  the  tissues  for  several  hours, 
water  evaporates,  and  causes  thereby  constant  and  continued  in- 
crease in  the  strength  of  the  solution.  So  that  if  the  original  solu- 
tion was  too  weak  to  cause  gangrene,  the  increase  by  evaporation 
may  do  so.  Tissues  do  not  bear  prolonged  contact  with  the  drug. 
The  first  local  effect  of  carbolic  acid  is  the  blanching  of  the  tissues 
and  anesthesia.  After  the  anesthesia  is  produced  the  patient  may 
not  be  able  to  recognize  that  the  tissues  are  being  damaged.  After 
the  tissues  are  blanched  they  become  black  and  a  dry  gangrene  is 
established.  This  may  involve  only  the  upper  layers  of  the  skin 
or  extend  to  any  depth,  so  that  a  whole  digit  or  a  large  mass  of 
tissue  may  be  lost. 

Decubitus,  or  Bed-sore. — This  is  a  pressure  necrosis,  favored 
by  the  poor  vitality  and  the  emaciated  and  often  unconscious  con- 
dition of  the  patient,  and  produced  by  compression  of  the  tissues 
between  the  bed  and  the  bony  eminences  of  the  body,  such  as  the 
sacrum,  the  trochanters,  the  heel,  the  malleoli,  the  spines  of  the 
vertebrae,  the  spine  of  the  scapula,  and  the  olecranon  process.  A 
similar  process  is  that  occurring  by  pressure  of  splints,  plaster 
casts,  and  other  surgical  appliances.  The  condition  occurs  usually 
in  patients  who  are  bedridden  and  unconscious,  or  who  are  poorly 
nursed,  or  in  those  whose  nerve-supply  to  a  portion  of  the  body  has 
been  rendered  functionless,  as  in  cases  of  paralysis  and  in  com- 
pression or  severance  of  the  spinal  cord.  In  these  latter  cases 
trophic  disturbances  also  favor  the  development  of  decubitus. 

The  first  evidence  of  decubitus  is  a  red  spot  at  a  point  where 
pressure  is  known  to  have  occurred.  This  spot  is  painful,  possibly 
tender,  if  the  general  condition  or  the  nerve-supply  does  not 
preclude  the  production  of  pain.  So  long  as  the  skin  remains 
red  there  may  be  a  chance  of  preventing  necrosis.  Further  press- 
ure guarantees  it.  When  necrosis  occurs  the  spot  becomes  whitish 
or  an  ashen  gray  and  loses  its  sensitiveness.  Later  it  becomes 
brown  or  black,  and  separates  as  a  dry  slough  from  the  living  tis- 
sues. Infection  is  very  likely  to  take  place  and  often  very  disas- 
trous in  large  bed-sores,  as  an  inflamed,  painful,  foul  ulcer  is  the 
consequence,  and  pyemia  or  septicemia  may  develop  at  any  time, 
especially  when  the  ulcers  are  large,  multiple,  or  improperly  at- 
tended. 


GANGRENE  195 

Ainhum. — This  is  a  curious  and  unexplained  type  of  gangrene. 
It  i-  a  disease  of  the  native  negro  of  the  west  coast  of  Africa  and 
occasionally  in  the  East  and  West  Indies.  Its  cause  is  not  known; 
soi n«'  authors  have  tried  unsuccessfully  to  identify  it  with  leprosy. 
1 1  : i fleets  men  more  frequently  than  women,  and  usually  attacks  the 
little  toe,  although  the  fourth  toe  or  the  little  finger  may  occasion- 
ally IK  attacked.  It  is  frequently  bilateral.  A  fissure  appears  on 
tin-  plantar  surface,  near  the  base  of  the  digit,  gradually  surrounds 
it  and  deepens  as  if  a  string  were  tied  around  it;  then  swelling  and 
gangrene  of  the  distal  part  occurs,  and  the  digit  drops  off;  healing 
follows,  and  the  general  condition  remains  undisturbed.  The 
appearance  of  ainhum,  under  various  circumstances,  has  led  to 
the  belief  that  a  variety  of  causes  may  produce  it  by  causing  the 
development  of  a  fibrous  band  around  the  digit. 

Treatment  of  Gangrene. — The  treatment  of  gangrene  assumes 
severa  1 1  )hases,  dependent  upon  the  type.  The  first  phase  is  that  of 
prevention.  In  all  cases  where  conditions  favor  the  development 
of  gangrene,  and  in  all  operations  the  nature  of  which  might  favor 
necrosis  of  tissue,  prophylactic  measures  must  be  instituted  and 
continued  until  the  danger  is  passed.  Thus,  ligation  hi  continuity 
must  lie  done  at  such  points  of  election  as  will  favor  the  most  effi- 
cient collateral  circulation,  and  the  part  whose  blood-supply  is 
dangerously  reduced  by  ligation  must  be  elevated,  kept  free  from 
const  riding  dressings,  held  at  or  above  the  normal  temperature, 
and  guarded  assiduously  against  infection;  failure  hi  any  one  of 
these  detail-  may  prove  disastrous,  and  each  added  offence  multi- 
plies the  danger  manyfold.  Further  than  this,  the  prophylaxis 
may  lie  briefly  summed  up  hi  the  statement  that  all  predisposing 
and  exciting  causes  of  gangrene  should  be  prevented  or  removed 
as  much  as  possible,  and  that  surgical  procedures  should  be  under- 
taken in  -ux-eptilile  individuals  only  when  absolutely  necessary. 

The  treatment  of  gangrene  requires  the  most  astute  judg- 
ment. The  (|ue-tions  usually  arising  are:  Whether  to  operate  or 
not?  Whether  it  is  better  to  wait  for  the  appearance  of  a  line  of 
demarcation?  At  what  level  above  the  gangrenous  limits  should 
removal  be  done?  Under  what  circumstances  is  it  necessary  to  do 
a  higher  amputation? 

The  iir>t  question  i-  answered  in  a  general  way  in  the  affirma- 
tive. ( langrennus  tissue  must  be  removed  from  living  tissue  or  it 
will  come  away  naturally  as  a  sphacelus.  In  the  majority  of  in- 
stance- it  i-  preferable  not  to  wait  for  natural  separation,  and  in 
all  cases  where  a  delay  could  cause  an  increase  in  the  quantity  of 
gangrenou^  tis-ue.  or  where  constitutional  symptoms  are  marked 
or  increasing  in  severity,  it  is  best  to  operate.  In  all  cases  where, 
owing  to  anatomi;-  conditions,  separation  of  the  living  from  the 


196  PRINCIPLES   OF   SURGERY 

dead  tissue  cannot  occur,  operate;  when  the  raw  surf  ace -left  by 
the  sphacelus  would  be  unduly  large  and  difficult  to  heal,  owing 
to  its  size  or  to  infection,  operate.  Admitting  that  a  gangrenous 
condition  is  self-limited,  if  it  extends  above  the  metacarpo-  or  meta- 
tarsophalangeal  articulations,  operate.  In  all  those  cases  where 
the  constitutional  condition  is  such  as  to  assure  recurrence  of 
gangrene  in  the  flaps  at  any  level,  do  not  operate.  In  those  cases 
in  which,  owing  to  the  extent  of  the  progress,  the  whole  gangrenous 
process  cannot  be  removed,  one  does  better  to  temporize.  In 
cases  of  multiple  gangrenous  foci  which  cannot  all  be  removed,  or 
which  indicate  that  the  tissues  generally  are  on  the  verge  of  necrosis, 
it  is  useless  to  attempt  operative  treatment.  In  those  cases  where 
it  is  impossible  to  remove  the  gangrenous  tissue  and  close  the  wound 
so  as  to  get  primary  union,  and  where  infection  has  not  occurred, 
but  can  be  prevented  more  certainly  by  non-operative  than  by 
operative  methods,  do  not  operate;  by  the  time  separation  of  the 
slough  has  occurred  the  general  condition  of  the  patient  may  be 
much  better  able  to  withstand  a  possible  infection. 

The  question  of  waiting  for  a  line  of  demarcation  must  be  de- 
termined not  only  by  the  type  of  gangrene,  but  by  the  behavior 
of  the  case  in  hand.  In  all  rapidly  spreading  cases  of  gangrene  one 
must  not  wait  for  the  development  of  a  line  of  demarcation;  that 
is  to  say,  if  infection  is  the  cause  of  the  gangrene,  or  if  it  is  a 
secondary  condition  and  accidental,  but  is  causing  rapid  spread 
or  producing  dangerous  symptoms,  no  delay  can  be  justifiable. 
In  cases  where  the  general  or  local  condition  is  found,  after  due 
delay,  to  be  such  that  a  line  of  demarcation  cannot  form,  operate 
without  loss  of  further  time.  Hence,  in  all  cases  of  microbic 
gangrene,  in  noma,  in  senile  gangrene,  after  it  has  extended  from 
the  toes  to  the  dorsum  of  the  foot,  and  in  diabetic  gangrene  one 
loses  important  time  by  waiting,  and  the  indication  is  to  remove  the 
parts  at  once,  provided  always  that  the  vitality  of  the  patient  is 
equal  to  the  extra  demands  imposed  by  the  operation  indicated. 
In  all  cases  where  the  gangrene  is  self-limited  or  dry,  one  may  usu- 
ally wait  a  reasonable  time  with  safety. 

The  distance  of  the  operative  incision  from  the  gangrenous 
borders  must  be  determined  for  each  case.  If  infection  is  the  cause, 
the  work  must  be  done  under  the  most  rigid  asepsis,  lest  reinfection 
establish  the  process  anew.  And,  on  making  incisions,  it  is  impera- 
tive in  these  cases  to  note  carefully  the  condition  of  the  tissues  for 
evidences  of  infection,  such  as  necrotic  fascia,  emphysema,  or 
venous  or  arterial  thrombosis,  which,  if  found,  demand  a  wider 
removal  of  tissue  with  a  fresh  set  of  instruments.  In  spreading  trau- 
matic gangrene  one  is  never  quite  safe  in  estimating  just  at  what 
level  an  amputation  can  be  safely  done.  If  a  line  of  demarcation 


GANGRENE  197 

has  formed,  it  may  be  simply  necessary  to  amputate  sufficiently 
high  above  the  line  to  obtain  satisfactory  flaps,  but,  when  the  gan- 
grene is  due  to  arteriosclerosis  or  venous  or  arterial  obstruction,  a 
new  feature  arises,  namely,  that  the  amputation  must  be  at  a  point 
sufficiently  high  to  get  an  adequate  collateral  circulation.  Hence, 
in  >uch  cases  it  is  often  necessary  to  amputate  near  the  knee,  above 
nr  l>elow,  for  a  gangrene  that  has  reached  no  higher  than  the  dor- 
sum  of  the  foot  or  the  ankle.  In  senile  gangrene,  diabetic,  and 
spreading  traumatic  gangrene  it  is  usually  necessary  to  amputate 
high  above  the  upper  border  of  the  gangrenous  tissue. 

The  method  of  managing  a  gangrenous  part  depends  on  whether 
infect  ion  and  decomposition  have  or  have  not  set  in.  If  no  infec- 
tion has  occurred,  the  tegument  and  the  cutis  should  be  kept  un- 
hroken  l»y  protecting  them  with  soft  dry  dressings  and  an  occa- 
sional application  of  some  antiseptic  solution,  as  bichlorid  of  mer- 
cury, alcohol,  carbolic  acid,  or  tincture  of  iodin.  The  last-named 
drug  i-  the  best.  If  infection  takes  place,  it  is  impossible  to  pre- 
vent rapid  decomposition  of  the  necrotic  tissue  and  the  associated 
inconvenience  and  discomfort.  The  use  of  deodorants  and  anti- 
septics. 1  iowever,  renders  the  situation  more  tolerable.  The  employ- 
nient  of  dre— ings  saturated  with  a  solution  of  potassium  perman- 
ganate, carbolic  acid,  creolin,  or  lysol  gives  the  combined  deodor- 
ant and  antiseptic  effects.  Under  certain  circumstances  it  may 
liec.iine  necessary,  even  in  hopeless  but  protracted  cases,  to  remove 
the  gangrenous  mass  and  deal  with  the  remaining  ulcerated  surface 

•  riling  to  indications. 

Arteriovenous  anastomosis  has  been  done  a  few  times  to  prevent 
uangrene  or  to  check  its  advance  with  certainly  enough  encourage- 
ment to  be  recommended  in  selected  cases.  Unfortunately,  the 
condition  of  the  vessels  and  the  difficulty  of  employing  the  method 
except  in  a  limited  way  renders  this  treatment  worthless  in  a  large 
percentage  of  cases. 

Treatment  of  Noma. — Noma  must  be  recognized  early  to  derive 
benefit  from  surgery,  and  the  treatment  must  be  thorough.  No 
consideration  can  be  entertained  for  the  disfigurement  that  will 
re.-ult ,  the  whole  attention  being  directed  toward  complete  destruc- 
tion of  the  necrotic  tissue  and  of  the  causative  infection.  This  is 
done  more  satisfactorily  with  the  actual  cautery.  Potential 
cauterants  may  ho  applied. in  default  of  the  former,  but  are  less 
controllable  and  certainly  less  efficient.  The  region,  both  buccal 
and  facial,  must  be  cleansed  as  perfectly  as  possible;  then  the  mass 
of  dead  tissue  is  removed  with  scissors  or  scalpel  and  the  whole  of 
the  >urface  cauteri/ed;  every  crevice  and  fissure  must  be  entered 
and  the  contained  infection  destroyed,  le-t  recurrence  in  the  whole 
area  take  place.  Here,  perhaps  above  all  other  types,  must  at  ten- 


198  PRINCIPLES   OF   SURGERY 

tion  be  paid  to  the  general  hygiene,  the  nutrition,  and  stimulation 
of  the  patient.  No  attempt  is  made  to  shape  flaps,  no  effort  to 
close  the  hideous  rent  in  the  face.  The  details  of  this  can  be  looked 
after  when,  and  are  justifiable  only  when,  recovery  is  made,  the 
tissues  completely  healed,  and  the  patient's  general  condition 
improved. 

Treatment  of  Decuhitus. — When  it  is  known  that  an  individual 
must  occupy  his  bed  for  a  considerable  tune,  and  when  dealing  with 
an  unconscious,  weak,  or  paralyzed  patient,  efforts  should  invari- 
ably be  put  forth  to  prevent  bed-sores.  This  is  all  the  more  neces- 
sary if  emaciation,  exhaustion,  and  a  feeble  circulation  add  to  the 
likelihood  of  their  production.  Such  individuals  should  not  be 
allowed  to  remain  long  in  one  position,  but  must  be  turned  from 
side  to  side  and  from  side  to  back  at  intervals  of  from  thirty  min- 
utes to  two  hours,  and  the  parts  massaged  once  or  twice  a  day  and 
rubbed  with  alcohol.  Above  all  things,  cleanliness  must  be  abso- 
lute, for  failure  in  this  respect  greatly  favors  the  occurrence  of  bed- 
sores. The  fact  that  the  patient  occupies  a  soft  bed  may  delude 
the  nurse  into  believing  that  her  attention  may  be  curtailed,  but  the 
ordinary  soft  bed  only  adds  to  the  difficulty  of  prevention  without 
reducing  the  danger.  If  the  patient  must  be  confined  to  bed  the 
remainder  of  his  life,  as  in  cases  where  the  spinal  cord  is  crushed,  it 
is  better  to  put  him  on  a  water-  or  air-bed  from  the  start. 

The  same  forethought  must  be  exercised  in  the  application 
of  splints  and  braces,  and  all  bony  prominences  must  be  padded 
abundantly  with  soft  wadding.  Afterward,  complaint  from  the 
patient  that  a  bony  eminence  has  become  painful  demands  an 
early  investigation  of  the  cause  of  pain. 

When  a  red  spot,  the  first  step  toward  decubitus,  appears, 
additional  activity  is  necessary.  All  pressure  must  be  removed 
from  this  spot,  and  this  requires  care  lest  the  additional  pressure 
at  other  points  cause  trouble,  where  the  patient  lies  on  a  surface 
threatened  with  a  bed-sore;  the  red  spot  is  protected  by  causing 
the  pressure  to  fall  on  the  regions  surrounding  it  by  the  employ- 
ment of  pads,  or,  preferably,  of  a  rubber  ring,  moderately  inflated 
with  air.  A  dressing  should  be  placed  over  the  red  spot,  simply 
of  dry  gauze,  or  it  may  be  dressed  with  a  dry  aseptic  powder, 
such  as  borated  talcum.  It  must  not  be  allowed  to  remain  wet  or 
filthy  under  any  circumstances.  Antiseptics  may  be  applied,  but 
not  in  sufficient  strength  to  damage  the  tissues.  A  solution'  of 
iodin,  1  to  3  per  cent.,  in  alcohol  is  perhaps  the  most  satisfactory. 
Gentle  massage  and  rubbing  with  alcohol  must  be  repeated  fre- 
quently during  the  day.  The  use  of  ointments  and  poultices  is 
likely  to  prove  harmful  by  maceration  of  the  epithelium  and  the 
admission  of  bacteria. 


GANGRENE  199 

\Yhen  the  pale  spot  appears  the  whole  purpose  is  to  prevent 
spreading  by  adopting  the  plan  just  outlined  above,  and  to  avoid 
infection.  It  is  better  that  the  slough  remain  in  situ  and  become 
<lry  than  that  it  should  come  away,  causing  an  open  ulcer,  sure  to 
become  infected,  thus  encouraging  the  spread  of  the  ulcer,  the 
occurrence  of  inflammation,  and  increasing  the  demands  already 
made  on  the  exhausted  vitality  of  the  patient.  Many  individuals 
who  suffer  from  bed-sores  die  of  septicemia  or  pyemia.  When  the 
>louijh  is  thrown  off  or  removed  the  remaining  ulcer  is  treated  ac- 
cording to  the  methods  mentioned  under  that  caption. 

Necrosis  of  internal  organs  may  occur,  and  the  necrotic  mass 
become  encysted  and  gradual  shrinkage  of  volume  ensue,  with 
little  or  no  constitutional  evidence  of  the  actual  pathology,  except 
where  sufficient  tissue  is  lost  to  interfere  perceptibly  with  function. 
If  infection  occurs,  abscess  or  one  of  the  general  septic  conditions 
will  arise  and  must  be  dealt  with  accordingly. 


CHAPTER  VIII 
ULCER 

ULCER  is  a  gradual  loss  of  tissue  by  disintegration  involving  a 
surface. 

Ulcer  is  distinguished  from  gangrene  by  the  fact  that  in  gan- 
grene gross  masses  of  tissue  die,  while  in  ulcer  the  mass  is  minute; 
in  gangrene  the  dead  tissue  remains  for  a  tune,  in  ulcer  it  is  gradu- 
ally thrown  off  and  lost.  As  gangrene  is  death  of  tissue  en  masse, 
so  ulcer  is  death  of  minute  quantities  of  tissue,  "the  molecular 
death  of  tissue." 

The  simple  fact  that  tissues  disintegrate  does  not  constitute 
ulcer;  these  tissues  must  be  lost  or  separated  from  the  living  tissue, 
and  there  must,  at  the  same  time,  be  a  loss  of  surface  covering,  so 
that  ulcer  is  possible  only  when  appearing  on  a  cutaneous,  mucous, 
or  serous  surface.  The  same  process  occurring  within  the  tissues 
or  organs,  but  not  affecting  a  surface,  is  called  necrobiosis. 

Etiology. — The  causes  of  ulceration  are  numerous,  but  produce 
their  effects  in  accordance  with  principles  already  sufficiently 
elaborated.  They  are  predisposing  and  exciting. 

The  predisposing  causes  of  ulcer  are  all  factors  interfering  with 
the  nutrition  of  the  part,  and  are  identical  with  the  predisposing 
causes  of  inflammation  and  gangrene.  If  the  predisposing  causes 
are  well  established,  and  interfere  extensively  with  the  nutrition 
of  the  part,  then  the  most  trivial  additional  disturbance  may  ini- 
tiate an  ulcer,  which  continues  to  spread  or  persistently  remains 
until  the  predisposing  factor  can  be  at  least  partially  eliminated. 
Among  the  most  frequent  predisposing  causes  of  ulceration  may 
be  mentioned  syphilis,  diabetes  mellitus,  gout,  uremia,  tuberculosis, 
general  anemia,  marasmus,  and  typhoid  fever  of  the  constitutional 
diseases;  and  of  the  local  conditions,  varicose  veins,  prolonged 
edema,  trophic  disturbances,  as  seen  in  diseases  and  injuries  of  the 
cord  and  large  cicatrices  whose  blood-supply  is  subnormal,  and 
malignant  tumors. 

The  actual  causes  of  ulceration,  on  the  contrary,  are  often 
capable  of  establishing  ulcers  without  synergic  predisposing  condi- 
tions. Ulcers  may  result  from  burns,  wounds,  contusions,  pro- 
longed pressure,  frost-bite,  escharotic  drugs,  electricity,  x-rays, 
radium,  and  bacteria;  these  are  identical  with  the  exciting  causes  of 
inflammation,  and  here,  as  in  inflammation,  bacteria  must  be  ac- 
200 


IL(  KH 


201 


eepted  as  the  chief  cause,  though  by  no  means  so  predominantly  so. 
In  almost  every  ulcerative  process  bacteria  soon  or  late  become 
implanted  and  their  action  is,  with  an  occasional  exception  (see 
Kry-ipelas),  in  line  with  the  agents  that  maintain  the  ulcer,  and 
often  they  alone  are  responsible  for  the  pathologic  picture.  Certain 
drugs  may  cause  ulceration  when  taken  in  overdoses,  as  seen  in 
mercurial  poisoning. 

Pathology  of  Ulcers  in  General. — Certain  fundamental  facts 
mu-t  In-  borne  in  mind  in  the  study  of  ulcers.  There  is  an  antago- 
ni-m  of  forces  in  action,  either  of  which  may  predominate.  The 
alterative  process  is  engaged  in  destroying  tissue  and  extending 
the  limits  of  the  ulcer,  and  associated  with  this  is  an  accidental  or 
e.— ential  infection.  On  the  other  hand,  the  healing  process  is 


Fig.  34. — Diabetic  ulcer  of  leg. 

bending  the  energies  of  the  tissues  to  repair  the  rent  made.  The 
healing  process  may  be  so  active  as  to  build  up  large  quantities  of 
ne\\  connective  tissue  around  and  beneath  the  surface  of  the  ulcer, 
which,  by  contraction,  limits  the  blood-supply  to  the  ulcer,  and 
thwarts  the  very  purpose  for  which  it  is  intended,  and  in  turn  must 
yield  to  the  ulcerative  process.  Hence,  an  ulcer  may  present  any 
variation  between  normal  healthy  granulations  and  a  surface  not 
only  devoid  of  signs  of  healing,  but  coverefl  with  necrotic  material 
or  a  psendomembrane,  and  possibly  -preading  rapidly.  The 
'onner  condition  is  ideal;  the  latter  represent-  the  wor-t  type-,  and 
ere  are  all  gradation-  between.  There  may  be  islands  of  grunu- 
tion-  -mall  or  large,  and  these  may  come  and  remain  a  while,  and 
en  l»e.  in  their  turn,  destroyed. 


202  PRINCIPLES   OF   SURGERY 

Shape. — The  shape  of  ulcers  is  round,  oval,  irregular,  or  linear; 
occasionally  an  ulcer  creeps  from  its  original  site  by  extending  on 
one  side  while  healing  on  the  other;  these  are  called  serpigenous 
ulcers. 

Margin. — The  edges  of  an  ulcer  may  be  smooth  and  flush  with 
the  surrounding  skin  or  elevated  above  its  level.  They  may  be 
soft  or  indurated,  and  this  induration  may  be  infiltrative,  cicatricial, 
or  malignant. 

The  area  of  the  ulcer  base  may  be  equal  to  that  of  the  opening 
in  the  tegument,  the  walls  vertical.  This  is  the  punched-out  ulcer. 
The  area  of  the  base  may  be  smaller  than  the  opening  in  the  tegu- 
ment, so  that  the  edges  are  spoken  of  as  sloping.  The  area  of  the 
base  may  be  larger,  often  much  larger,  than  that  hi  the  tegument, 
and  this  is  called  an  undermined  ulcer. 

The  base  of  an  ulcer  may  be  smooth  and  covered  with  granu- 
lations; it  may  be  covered  with  necrotic  material  or  a  false  mem- 


c 

Fig.   35. — Margin  of  ulcers.     Schematic:  a,   Sloping  or  everted   edges;   b, 
punched-out  ulcer;  c,  undermined  ulcer. 

brane;  it  may  be  devoid  of  all  the  preceding  and  expose  the  ana- 
tomic structures  in  its  base;  it  may  be  irregular  or  mouse  eaten. 

The  discharge  from  the  surface  of  an  ulcer  may  be  abundant 
or  scanty.  It  may  be  serous,  purulent,  seropurulent,  or  sanious, 
according  to  the  type  of  ulcer  and  the  condition  of  the  raw  surface. 
In  ulcers  where  the  death  of  tissue  is  rapid,  and  in  those  cases  not 
kept  clean,  the  discharge  is  fetid  and  at  times  may  be  offensive. 
This  is  especially  likely  to  occur  in  phagedenic,  rodent,  and  indo- 
lent ulcers. 

Classification. — The  classification  of  ulcers  may  be  made  easier 
by  placing  them  into  two  grand  divisions,  namely,  non-specific,  or 
simple,  ulcers  and  specific  ulcers.  In  the  first  group  are  placed  all 
those  which  depend  on  ordinary  non-specific  causes  or  the  ordinary 
pyogenic  bacteria,  and  those  cases  arising  from  constitutional  con- 
ditions which  are  not  of  parasitic  origin;  and,  in  the  second,  all 
those  produced  by  specific  infection,  whether  it  acts  locally  or  is 
simply  a  local  manifestation  of  a  general  infection;  ulcers  depend- 
ent upon  malignant  processes  are  placed  in  this  group.  However, 


ULCER  203 

a-  any  ulcer,  of  whatever  origin,  will,  from  a  surgical  standpoint, 
(•(inform  to  one  of  a  few  types,  it  is  deemed  better  to  study  them 
in  the  light  of  these  types  rather  than  to  enter  into  the  endless 
detail-;  imposed  by  studying  them  from  the  standpoint  of  etiology. 

Granulating,  Healthy,  or  Healing  Ulcer. — Much  discussion  has 
been  wasted  for  and  against  placing  this  condition  in  the  category 
of  ulcers.  Admitting  that  good  arguments  are  made  by  both 
sides,  it  remains  a  fact  that  surgeons  continue  to  speak  of  healthy 
or  healing  ulcer,  in  spite  of  the  glaring  contradictions  between  the 
term-  'healthy"  and  "healing"  and  the  definition  of  ulcer.  Yet,  if 
we  ran  understand  definitely  what  is  meant  by  the  term  no  harm  can 
come;  on  the  other  hand,  it  would  be  equally  contradictory  to  omit 
it .  f«  >r  then  an  ulcer  would  cease  to  be  an  ulcer  when  it  began  to  heal. 

A  granulating  ulcer  is  an  ulcer  healing  normally,  and  cannot 
be  distinguished  from  a  wound  healing  by  second  intention; 
pathologically  they  are  identical.  It  is  the  ideal  state  to  which  it 
i-  the  hope  of  the  surgeon  to  bring  every  ulcer  which  he  undertakes 
to  cure  as  an  open  sore. 

The  granulating  tissue  of  a  healthy  ulcer  is  firm  and  pink, 
and  the  surface  is  covered  with  small  granular-shaped  bodies  of  new 
tissue.  There  may  be  a  serous  or  seropurulent  discharge  from  the 
surface,  but  the  quantity  is  not  great.  The  margin  of  the  ulcer  is 
encircled  by  a  bluish-white  line  of  new-formed  epithelium,  extend- 
ing from  the  skin  on  to  the  surface  of  the  granulations,  which  grows 
on  the  average  of  2  to  3  mm.  per  week.  There  will  be  little  varia- 
tion of  the  surrounding  tissue  from  normal. 

Treatment. — No  treatment  is  necessary  beyond  the  applica- 
tion of  clean  dressings  as  the  case  may  demand,  cleansing  the  sur- 
faee  and  surrounding  skin  at  each  dressing  preferably  with  dry  soft 
-ponge-  made  of  gau/e,  or  by  employment  of  normal  salt  solution. 
If  for  any  reason  medicaments  must  be  applied,  one  must  make 
sure  they  are  mild  and  harmless  to  granulation  tissue.  A  little 
calomel  or  boric  acid  may  be  used,  but  one  can  hope  to  gain  little 
advantage  l>y  meddling  with  normal  healing.  The  repeated  ap- 
plication of  liichloridot  mercury  solutions  is  positively  harmful,  and 
even  water  or  saline  solution  is  of  very  questionable  practice. 

Fungous,  Exuberant,  or  Hypertrophic  Ulcer. — This  type  of 
ulcer  i-  charaeteri/ed  by  an  excess  of  granulation  tissue  which 
i-  unhealthy.  The  mass  of  granulations  may  extend  above  the 
level  of  the  -urroundini:  integument,  and  is  soft,  flabby,  at  times 
-eniigelatinou-.  pale,  and  ea>ily  broken  down.  The  skin  edges 
show  little  or  no  tendency  to  cover  the  granulation-  with  epi- 
thelium, and  the  >i/.e  of  the  ulcer  remain-  the  same  or  become- 
: .  while  the  ma—  of  exuberant  ti  —  ue  continue-  to  grow.  The 
»ive  granulation-  are  -pokeii  of  by  the  laity  as  "proud  tle-h." 


204  PRINCIPLES   OF   SURGERY 

Exuberant  ulcer  occurs  more  readily  in  the  anemic,  the  tuber- 
cular, in  alcoholics,  and  those  whose  hygienic  surroundings  are 
bad.  The  great  dread  of  this,  form  of  ulcer  entertained  by  the 
laity  has  no  reasonable  foundation. 

Treatment. — The  first  desideratum  in  exuberant  ulcer  is  to  cor- 
rect the  predisposing  condition,  and  to  administer  tonics,  stimu- 
lants, improve  the  surroundings,  and  correct  the  diet. 

The  local  treatment  consists  in  the  removal  of  all  unhealthy 
granulations  by  the  knife,  curet,  or  cautery,  and  the  employ- 
ment of  Bier's  hyperemic  treatment  once  or  twice  daily.  In  the 
beginning,  when  these  ulcers  first  show  evidence  of  their  true  nature, 
the  topical  application  of  a  strong  solution  of  silver  nitrate  or 
carbolic  acid  will  often  correct  the  condition.  After  removal  of 
the  hypertrophic  tissue,  the  surface  may  be  painted  with  iodin  or 
dusted  with  iodoform  at  every  dressing  or  at  alternate  dressings. 
A  sharp  outlook  must  be  kept  for  reappearance  of  unhealthy  granu- 
lations and  action  taken  accordingly. 

Chronic,  Callous,  or  Indolent  Ulcer. — There  are  many  varieties 
of  chronic  ulcer  which  must  be  discussed  somewhat  in  detail.  All 
chronic  ulcers  are  necessarily  indolent,  but  they  can  be  described 
as  callous  only  when  a  considerable  amount  of  cicatricial  tissue  has 
formed  in  the  base  and  around  the  edges  of  the  ulcer,  giving  it  a 
hard  feel,  and  making  it  more  or  less  immovable  by  the  dense  at- 
tachment of  this  new-formed  tissue  to  the  underlying  structures. 

The  most  frequent  type  of  chronic  ulcer  is  the  varicose  ulcer 
and  certain  of  the  specific  ulcers,  particularly  the  tertiary  syphilitic. 
When  both  factors  are  active  the  ulcers  are  rendered  much  more 
stubborn.  The  beginning  of  chronic  ulcer  is  usually  accreditable 
to  an  injury,  which  may  be  very  slight,  such  as  a  scratch  or  a  slight 
bruise  in  a  region  rendered  favorable  on  account  of  varicose  veins, 
However,  the  ulcer  may  begin  without  such  injury.  It  is  found  usu- 
ally on  the  leg  or  foot,  and  is  associated  with  trophic  disturbances 
or  varicose  veins,  or  comes  as  a  sequel  to  venous  thrombosis  fol- 
lowing a  general  infection  like  typhoid  fever.  In  syphilitics  this 
ulcer  may  appear  as  a  tertiary  lesion  at  various  points  on  the  body, 
but  even  in  these  it  is  seen  more  often  on  the  leg. 

Chronic  ulcer  may  be  very  small,  and  reach  only  through  the 
skin,  or  it  may  be  so  extensive  that  practically  the  whole  surface  of 
the  leg  from  knee  to  ankle  is  affected,  and  may  extend  in  depth  until 
muscles,  periosteum,  and  bone  are  attacked.  This  ulcer  is  seen 
more  frequently  in  the  old,  although  it  may  be  seen  occasionally  in 
young  individuals.  The  ulcer  starts  out  from  the  beginning  as  a 
chronic  lesion,  and  may  continue  indefinitely,  thirty  or  forty  years, 
either  maintaining  a  fairly  uniform  size  or  gradually  extending  in 
diameter  and  depth  from  the  starting-point.  Syphilitic  ulcers  are 


TLCKK 


205 


likely  to  extend  in  breadth  and  depth  than  non-syphilitic. 
Small  patches  of  granulations  spring  up  occasionally  and  disap- 
pear without  having  withstood  the  ulcerative  process  long.  The 
surface  is  covered  with  necrotic  tissue  and  discharges  a  serous  or 
seropurulent  fluid,  which  may  be  at  times  hemorrhagic.  The 
surrounding  tissues  are  usually  swollen,  indurated,  or  edematous, 
and  inflammation  of  the  tissues  may  recur  from  time  to  time.  The 
surrounding  tissues  often  develop  an  intolerable,  intractable  eczema 


Fiji.  .'!»;.     Indolent  ulcer  of  the  leg. 

which  annoy-  the  patient  far  more  than  the  ulcer  does.     Pigment e<l 

often  >urroun<l  the  edges  of  the  ulcer,  and  may  be  seen  scat- 

tered  about  over  the  atTeeted  le<;.     They  are  due  to  deposits  of 

hemoglobin  from  stagnant  blood,  or  to  -ear-  from  similar  ulcers 

which  have  healed.     The  ulcers  are  usually  not  painful,  but  may 

lie  extremely  -en-itive,  and  show  the  characteristics  of  irritable 

ulcer.     1'nle—  kept  dean  the-e  ulcer-  are  very  foul  and  offensive. 

/V<»./miN/.x'.     The  proi:no-i-  of  chronic  ulcer  is  poor.     The  ulcer 

can  be  cured  usually  if  the  patient  will  submit  to  the  neee— ary 


206  PRINCIPLES   OF   SURGERY 

restraint,  and  this  he  is  often  loath  to  do.  However,  after  healing 
is  complete,  the  return  to  normal  practices  is  very  frequently  fol- 
lowed by  recurrence.  In  the  larger  ulcers  loss  of  limb  is  frequently 
the  only  hope  of  relief. 

Treatment. — The  first  condition  of  successful  treatment  of 
chronic  ulcer  is  absolute  control  of  the  patient.  More  failures  are 
perhaps  attributable  to  this  fact  than  can  be  found  in  any  other 
curable  condition.  Without  such  co-operation  success  is  pre- 
cluded in  all  severe  cases  and  improbable  in  many  of  the  milder 
ones.  The  first  step  of  treatment,  therefore,  is  to  rest  and  elevate 
the  part.  The  rest  must  be  absolute  and  the  elevation  sufficient  to 
prevent  venous  stasis.  If  syphilis  is  a  possible  factor,  antisyphilitic 
treatment  must  be  directed  pro  re  nata. 

Second.  The  ulcer  must  be  kept  clean  and  the  accumulation 
of  dead  epithelium  and  dried  secretions  around  the  edges  must  be 
removed  occasionally,  and  uniform  pressure  made  over  the  ulcer 
and  the  adjacent  region  by  the  application  of  elastic  dressings  or 
stockings.  Unna's  paste  or  adhesive  strips  imbricated  and  allow- 
ing a  small  vent  for  the  discharge  accomplish  this  end  admirably. 
The  frequency  of  these  dressings  depends  on  the  individual  case. 

Third.  If  the  ulcer  is  old  and  calloused  the  cicatricial  tissue 
should  be  removed  at  the  beginning,  preferably  by  incising  the 
healthy  tissue  around  the  border  and  dissection  of  the  whole  ulcer 
base  in  one  block,  followed  by  ordinary  after-treatment  of  the 
wound;  or  the  base  of  the  ulcer  may  be  incised  and  scraped  away 
with  a  sharp  curet.  Cauterization  of  the  ulcer  with  the  actual 
cautery  accomplishes  the  same  end.  If  bone  is  found  diseased, 
but  insufficiently  so  to  demand  amputation,  the  necrosed  portion 
must  be  removed.  Whether  operative  treatment  has  been  neces- 
sary or  not,  it  is  very  beneficial  to  use  Bier's  hyperemic  treatment 
or  Wright's  solution,  which  contains  citric  acid,  |  of  1  per  cent.; 
sugar,  10  per  cent.;  water,  q.  s.  ad  100  per  cent.,  which  is  to  be  kept 
constantly  applied  to  the  ulcer  by  saturating  the  dressings  several 
times  a  day.  This  may  be  used  conjointly  with  Bier's  hyperemia. 

After  granulation  has  advanced  sufficiently  it  is  always  better 
to  skin-graft  large  ulcers.  If  varicose  veins  are  present  they  may 
be  dealt  with  either  by  palliative  treatment,  such  as  the  employ- 
ment of  elastic  stockings,  or  by  radical  operation.  The  patient 
should  not  be  permitted  to  return  to  his  usual  vocation  without  such 
care  of  his  varices,  and  should  be  instructed  to  return  for  treatment 
on  the  first  evidence  of  recurrence  of  the  ulcer. 

If  it  is  absolutely  necessary  to  treat  a  chronic  ulcer  and  allow 
the  patient  to  continue  on  foot,  there  is  no  question  but  that  uni- 
form pressure,  as  accomplished  best  by  application  of  Unna's 
paste,  is  the  most  satisfactory  method  of  treatment. 


ULCER  207 

Painful,  Irritable,  Ere  thistle,  or  Congested  Ulcer. — This  ulcer 
is  characterized  by  its  chronicity  and  by  its  painfulness  and  sen- 
sitiveness. It  is  painful  on  account  of  exposure  of  a  nerve  from 
cl»->t  ruction  of  the  nerve-sheath.  This  point  can  be  located  by 
touching  the  surface  of  the  ulcer  with  a  small  probe;  the  remainder 
of  th<-  ulcer  surface  is  usually  not  sensitive.  The  sensitiveness  is 
MI  ureat  that  dressings  are  intolerable,  and  even  exposure  to  the 
atmosphere  causes  pain. 

Painful  ulcers  are  seen  more  frequently  in  women  who  have 
nien-trual  disorders,  and  as  a  complication  of  varicose  veins  and 
in  the  anus,  usually  at  the  posterior  commissure,  where  they  are 
called  fi-sures,  and  in  the  lips.  When  they  appear  on  the  leg,  their 
favorite  site  is  over  or  near  the  internal  malleolus ;  at  this  point  the 
fir-i  evidence  is  the  appearance  of  a  red  spot,  which  gradually  be- 
come- rvanotic,  and  breaks  down  spontaneously  or  following  slight 
trauma,  and  then  gradual  enlargement  follows,  with  thickening  of 
the  connective  tissue  and  induration  of  the  base  and  edges  of  the 
ulcer  and  attachment  of  its  base  to  underlying  structures.  Epider- 
mi/at  ion  and  granulations  do  not  appear,  and  there  is  not  only  great 
difficulty  in  relieving  the  suffering  and  healing  the  ulcer,  but  con- 
sideraMe  probability  of  its  recurrence.  Aside  from  the  subjective 
symptoms  and  the  location,  it  is  impossible  to  distinguish  this  ulcer 
from  an  indolent  ulcer. 

Fi— ure  in  ano  results  from  the  passage  of  hard  fecal  masses, 
and.  there-fore,  is  traumatic,  and  is  predisposed  to  by  all  diseased 
conditions  which  reduce  the  vitality  of  the  anal  lining  and  those 
favoring  con-tipation.  The  ulcer  is  longitudinal,  and  may  be 
situated  at  any  point  on  the  circumference  of  the  anus,  but  usually 
at  t  he  posterior  commissure.  At  the  lower  end  of  the  linear  vertical 
fi>sure  there  is  often  found  a  mass  of  thickened  tissue,  resembling 
>ome\\hat  an  external  hemorrhoid,  and  called  a  sentinel  pile. 
<  >cca-ionally  this  ulcer  is  irregular  in  shape.  It  is  painful  to  the 
limit  of  tolerance  after  the  passage  of  motions  or  flatus,  and  causes 
con-tant  dread  and  postponement  of  defecation.  Caused  by 
trauma,  it  is  maintained  by  it.  These  ulcers  are  often  minute  and 
e-cape  observation,  the  symptoms  being  attributed  to  lesions  of 
some  anatomically  correlated  structure.  They  are  not  indurated. 

Fi— un-  nf  the  lip  rarely  partake  of  the  nature  of  chronic  ulcer. 

Trratiinid.  Hilton  n commended  location  and  excision  of  the 
painful  >pot  with  a  -mall  amount  of  surrounding  tissue.  If  the 
whole  -urface  i-  -rn-itive.  complete  direction  or  crucial  incisions 
re  recommended.  The  pain  may  lie  controlled  by  local  applica- 
on-  ,,f  r.irain  and  kindred  drugs,  opium,  chloral,  and  similar 
lodyne-.  in  the  form  of  an  ointment. 

Fi--un-  may  always  he  relieved  by  inci>ion  and  cauterization 


208  PRINCIPLES   OF   SURGERY 

or  curettage  of  the  ulcer  surface.  But  it  is  preferable  to  excise  the 
fissure  and  suture,  or  to  make  an  incision  through  the  long  axis  of 
the  ulcer,  well  down  into  the  substance  of  the  sphincter  muscle, 
sufficiently  deep  to  put  that  portion  of  the  muscle  influencing  the 
ulcer  at  rest.  The  general  condition  must  be  built  up  and  the 
habits  regulated  to  obtain  or  maintain  a  cure. 

Malum  Perforans  Pedis,  or  Neuroparalytic  Ulcer. — This  ulcer, 
as  its  name  would  indicate,  occurs  on  the  foot,  is  chronic,  and 
is  usually  associated  with  some  disturbance  of  the  nerve-supply  to 
the  part. 

The  causative  conditions  most  frequently  held  responsible 
for  the  lesion  are  locomotor  ataxia,  syringomyelia,  paretic  dementia, 
spina  bifida,  traumatisms,  and  inflammation  of  the  nerves,  their 
centers,  or  the  encasing  bony  tissue,  diabetic  neuritis,  tumors  of 
the  nervous  system  and  arteritis,  syphilitic  or  alcoholic,  and  vas- 
cular sclerosis.  The  causative  factors,  in  brief,  are  reduced  sensi- 
bility and  sclerosis.  It  is  sometimes  seen  in  anesthetic  leprosy. 
The  condition  depends  upon  continued  pressure  for  its  exciting 
cause. 

Malum  perforans  occurs  on  the  foot  at  one  of  the  three  weight- 
bearing  areas  of  the  sole,  namely,  the  heel,  the  head  of  the  fifth 
metatarsal,  or  the  head  of  the  first  metatarsal  bone;  hi  the  majority 
of  cases  it  occurs  at  the  last-named  spot.  It  is  usually  found  in 
adults  well  advanced  in  years,  but  has  been  seen  in  children.  The 
first  evidence  is  usually  a  callous  spot  on  the  sole  of  the  foot,  but 
now  and  then  it  begins  in  a  wound  or  a  new-formed  bursa.  The 
onset  is  announced  by  a  localized  inflammation  which  may  suppu- 
rate, and  is  followed  by  necrosis  of  the  tissue.  The  slough  falls 
away  and  an  ulcer  forms,  deep,  circular,  with  distinct  edges,  which 
are  hard  and  abrupt  or  undermined.  The  ulcer  may  remain  in 
statu  quo,  or,  especially  if  pressure  is  continued,  may  slowly  extend 
more  deeply,  and  involve  bone  or  joint  in  its  necrosis.  Granula- 
tions are  not  present,  and  a  thin,  watery,  or  purulent  discharge  is 
poured  out.  The  ulcer  is  painless  and  the  surrounding  tissues  are 
anesthetic  or  analgesic.  Trophic  disturbances  of  the  integument 
and  nails,  especially  hypertrophy,  are  often  associated  with  malum 
perforans.  The  ulcer  may  eventually  heal,  and  without  known 
provocation  recur,  and  this  healing  and  recurrence  may  alternate 
with  each  other  for  years.  The  ulcer  is  usually  resistant  to  treat- 
ment. 

Treatment. — First,  all  pressure  should  be  removed  and  the  foot 
placed  at  rest.  This  point  needs  to  be  insisted  upon,  because  in  the 
painless  condition  the  patient  cannot  tell  when  he  is  doing  injury. 
The  ulcer  must  be  cleansed  or  dissected  out  or  the  free  overhanging 
edges  cut  away  and  the  cavity  thoroughly  curetted.  Heat  may  be 


ULCER  209 

applied  by  immersion  in  hot  water  for  half  an  hour  or  more  twice 
a  day.  Bier's  treatment  and  the  stimulating  and  mildly  antiseptic 
drugs,  such  as  iodoform  or  balsam  of  Peru,  may  be  applied.  Neu- 
reetasy  of  the  main  nerve-supply  of  the  part  is  recommended  as 
highly  ffficient. 

In  any  case,  the  predisposing  cause  must  be  sought  and  as  far 
as  possible  corrected.  Recurrence  is  frequent,  and  instructions 
should  be  given  to  avoid  unnecessary  pressure  on  the  dangerous 
point-  and  to  inspect  the  foot  frequently  for  signs  of  return. 

Phagedenic  Ulcer,  Spreading  Ulcer. — Phagedenic  ulcer  is 
cau-ed  by  infection  in  most  cases;  a  similar  condition  appears  oc- 
ra-ionally  as  the  result  of  cachectic  conditions  associated  with  pro- 
tracted exhaustive  diseases,  but  the  real  cause  here  is  infection, 
which  flourishes  more  rapidly  because  of  diminished  tissue  resist- 
ance. The  most  frequent  phagedenic  ulcer  is  the  chancroid,  or  soft 
chancre,  which  is  transmissible,  usually  by  sexual  contact.  Pha- 
gedenic ulcer  may  start  de  novo  as  such,  or  it  may  become  engrafted 
upon  some  other  type  of  ulcer  or  on  a  wound.  The  constitutional 
condition  seems  to  play  little  part  in  chancroidal  ulcers.  An 
abrasion  is  necessary  for  the  admission  of  infection,  but  the  abra- 
sion may  be  very  minute.  Within  a  very  few  days,  at  times  within 
twenty-four  hours  from  the  date  of  infection,  a  small  inflammatory 
nodule  appears  and  soon  becomes  a  pustule;  if  the  atrium  is  suffi- 
ciently large,  no  pustule  forms.  The  pustule  ruptures  and  a  well- 
defined  ulcer  re-nits,  which  continues  to  discharge  pus  and  to  en- 
large, while,  at  the  same  time,  it  extends  in  depth.  The  ulcer  is 
very  frequently  undermined  and  often  forms  a  tube-like  subcu- 
taneous  channel.  Hence  the  superficial  evidence  is  misleading 
as  to  the  true  condition,  and,  unless  thorough  examination  is  made, 
the  Undermined  portion  will  escape  untreated.  These  ulcers  may 
spread  slowly  or  rapidly;  when  they  spread  rapidly  they  frequently 
show  necrotic  pieces  of  tissue  of  considerable  size  and  destroy  con- 
siderable volumes  of  tissue.  The  glans  penis  is  often  considerably 
di-figured  by  them,  but  is  rarely  completely  destroyed.  They 
produce  glandular  involvement  and  the  glands  often  suppurate. 
This  pus  may  be  sterile  or  may  contain  innocuous  bacteria,  or  it  may 
contain  numerous  virulent  micro-organisms,  a  fact  that  explains 
the  difference  in  behavior  of  the  wounds  when  e\ci>ion  of  the 
lymph-node-  i-  contemplated.  In  the  former  two  conditions  the 
wound  behave-  kindly  and  heals  rapidly,  while  in  the  latter  anew 
ulcer  i-  established,  control  of  which  may  not  be  gained  until  it  has 
grown  several  inches  in  diameter.  Hence,  incision  is  better  here. 
The  pus  from  the  primary  >«>re  i-  always  infection-.  The  primary 
sore  and  the  chancroidal  bubo  are  nearly  al\va\  -  more  or  less  pain- 
ful and  -en-itive.  and  this  is  u-ed  as  a  differential  point  between  the 
11 


210  PRINCIPLES   OF   SURGERY 

soft  chancre  and  true  or  hard  chancre.  The  latter  does  not 
spread  extensively  as  soft  chancre  does,  does  not  suppurate,  and 
does  not  produce  extensive  or  marked  glandular  enlargement,  and 
the  gland  or  glands  which  do  enlarge  are  painless  and  non-suppu- 
rative.  Mixed  infection  is  frequent,  and  it  is  then  impossible  to  say 
whether  syphilitic  infection  is  present  or  absent,  except  by  the  dis- 
covery of  Spirocheta  pallida,  the  appearance  of  secondary  symp- 
toms, or  a  positive  Wassermann  reaction,  as  the  activity  of  the 
chancroidal  infection  obscures  all  characteristics  of  the  syphilitic 
primary  sore. 

Operations  for  such  conditions  as  varicocele,  hydrocele,  circum- 
cision, and  especially  hernia  must  not  be  undertaken  during  the 
existence  of  phagedenic  ulcers,  for  it  is  well-nigh  impossible  to 
avoid  infection  at  the  time  of  operation  or  subsequently. 

Phagedenic  ulcers  are  occasionally  so  rapid  in  their  spread  as  to 
deserve  the  title  of  gangrenous  ulcer.  In  these  ulcers  anaerobes 
are  recoverable,  and  are  probably  the  cause  of  most,  if  not  all, 
such  cases,  a  fact  which  closely  allies  them  to  the  lesions  produced 
by  the  Bacillus  aerogenes  capsulatus. 

Phagedenic  ulcers  are  often  multiple,  and  are  almost  certain  to 
occur  in  folds  of  the  skin  or  mucous  membrane  which  covers  the 
ulcer.  They  may  coalesce  and  form  an  ulcer  covering  the  whole 
region  formerly  occupied  by  numerous  ulcers. 

Prognosis.- — The  prognosis  of  phagedenic  ulcer  is  good  except 
where  the  general  condition  of  the  patient  is  so  wretched  that 
healing  cannot  take  place.  Frequently  they  continue  to  spread 
for  five  or  six  weeks,  the  destructive  stage,  and  then  without  treat- 
ment the  surface  cleans  off,  the  dead  tissue  comes  away,  and  the 
denuded  base  assumes  the  characteristics  of  healing  ulcer,  the  stage 
of  repair. 

Treatment. — The  prevention  of  phagedenic  ulcer  is  the  same  as 
that  of  any  other  virulent  infection.  No  wounds  are  to  be  made 
in  the  infected  region  except  under  direst  necessity,  and  if  they 
become  necessary  they  should  be  sealed  up  with  collodion  or  other- 
wise until  healing  is  complete. 

When  phagedena  is  recognized,  the  first  step  necessary  is  that 
the  whole  region  surrounding  the  sore  be  rendered  aseptic.  The 
necrotic  surface  should  be  cleansed  and  all  products  removed, 
all  sinuses  recognized  and  slit  up.  Then,  under  general  or  local 
anesthesia,  the  whole  ulcer  surface  must  be  thoroughly  cauterized 
as  well  as  all  raw  surfaces  made  by  incision.  If  any  part  of  the 
infection  is  left  undestroyed  recurrence  is  certain.  Delay  to  use 
the  cautery7,  actual  or  potential  (nitric  acid  is  the  favorite),  means 
usually  a  greater  sacrifice  of  tissue  than  cauterization  would  make. 
Every  care  is  needed  to  prevent  reinfection.  I  have  seen  it  pro- 


ULCER  211 

1  by  contact  of  the  almost  healed  ulcers  with  infected  clothing 
which  a  slovenly  patient  had  refused  to  change.  After  cauteriza- 
tion it  is  best  to  tell  the  patient  that  the  sore  will  be  larger  for  a 
fc\\  <l:i\  -  owing  to  separation  of  the  eschar.  After  cauterization, 
with  an  aseptic  dressing  until  granulations  appear  and  the 
eschar  is  thrown  off.  Then  the  treatment  should  be  the  same 
a>  t  hat  of  healing  ulcer.  It  is  often  advisable  to  apply  a  wet  dress- 
ing, and  an  aqueous  solution  of  nitric  acid  1  :  500  is  perhaps  the 
most  satisfactory.  On  the  other  hand,  some  phagedenic  ulcers 
refuse  to  heal  under  wet  dressing,  and  must  be  dressed  with  a 
darting-powder,  with  balsam  of  Peru,  or  with  a  simple  dry  dressing. 

Rodent  or  Eating  Ulcer. — This  ulcer  is  an  ulcerative  epithelioma. 
The  tumor  appears  especially  on  the  exposed  surfaces  of  the  body, 
usually  on  the  cheek,  lower  lip,  nose,  ear,  eyelids,  and  brow,  and  far 
less  frequently  on  the  hands.  This  tumor  ulcerates  as  it  grows,  and 
a  shallow,  irregular,  or  round  sore  forms,  showing  no  granulations, 
for  the  most  part  dry  or  discharging  a  little  serous  or  bloody 
fluid,  and  surrounded  by  a  border  which  is  narrow  and  usually  very 
little  raised.  Occasionally  the  surrounding  border  is  nodular. 
The  ulcer  surface  may  be  seen  at  times  raised  above  the  level  of 
surrounding  epithelium  and  even  overhanging  it,  constituting  the 
so-called  elevated  ulcer.  It  is  entirely  unlike  exuberant  ulcer. 
These  ulcers  are  indolent  and  persistent,  and  will  not  respond  to 
the  ordinary  treatment  of  ulcers.  They  sometimes  heal  at  one 
point,  hut  show  their  true  nature  by  continuing  to  spread  at  an- 
other. They  are  usually  painless,  but  by  no  means  constantly  so. 
When  a  large  amount  of  connective  tissue  forms  in  the  base,  the 
surrounding  tegument  is  drawn  into  creases  and  folds  radiating 
from  the  edges  of  the  ulcer. 

Treatment  is  given  under  Epithelioma. 

Marjolin's  Ulcer. — Marjolin's  ulcer  is  an  ulcer  resulting  from 
the  l.reaking  down  of  an  old  scar,  and  is  usually  epitheliomatous  in 
character.  If  it  is  not  epitheliomatous  it  resembles  indolent  ulcer, 
and  must  be  treated  as  such.  No  time  should  be  lost,  however,  in 
determining  ju-t  \\hether  it  is  malignant  or  not.  In  case  micro- 
scopic examination  fails  to  prove  malignancy,  the  treatment  should 
be  directed  along  the  lines  given  under  Indolent  Ulcer. 

In  ulceration  of  any  type  the  anatomically  connected  lymph- 
node-  may  be  found  enlarged  as  a  consequence  of  infection.  In 

•cific  primary  ulcer-  it  is  the  rule  to  find  such  lymphatic  involve- 
ent.  which  u-ually  gives  no  further  concern  after  relief  from  the 
cer.  l.ut  occa-ionally  they  demand  further  attention,  especially  if 

e  call>e  he  tuhercle  Itacilli. 

Ulcers  of  the  Mucous  Membrane. — Aside  from  the  fundamen- 
-  of  ulcer,  as  given  above,  others  are  found  affecting  the 


212  PRINCIPLES   OF   SURGERY 

mucous  membrane  and  occasionally  the  serous  membranes,  although 
these  latter  are  usually  more  of  pathologic  interest,  or,  if  of  surgical 
importance,  their  role  is  a  minor  one  compared  with  the  more  se- 
rious lesions  of  which  they  represent  an  important  incident.  Ulcers 
of  the  articular  surfaces  are  thus  only  a  manifestation  of  articular 
inflammation  or  infection,  and  those  of  the  larger  blood-vessels 
represent  simply  a  phase  in  the  advance  of  atheroma  or  arterio- 
sclerosis. Ulcers  of  the  mucous  membrane  are  of  sufficient  im- 
portance to  demand  consideration.  They  are  usually  seen  in  the 
mouth,  upper  air-passages,  larynx,  bladder,  vagina,  small  intestine, 
stomach,  colon,  or  rectum.  Ulcers  may  be  produced  on  any  mu- 
cous surface  by  continued  pressure  or  erasion,  as  is  seen  in  cases 
where  stones  have  remained  for  a  long  period  in  the  bladder,  gall- 
bladder, or  pelvis  of  the  kidney.  With  the  exception  of  the  stom- 
ach, upper  duodenum,  and  the  rectum  the  majority  of  ulcers  of  the 
mucous  membrane  are  due  to  such  erasion,  specific  infections,  or 
malignancy.  But  in  the  stomach,  and  that  portion  of  the  duo- 
denum closely  allied  to  it  in  function  as  well  as  position,  and  in  the 
rectum  and  colon  ulceration  appears  independent  of  these  influ- 
ences. When  an  ulcer  appears  in  any  hollow  viscus  the  symptoms 
may  be  obscure  or  entirely  wanting,  and  its  presence  be  detected 
only  by  the  accidental  discovery  of  blood  in  the  discharges  from 
the  particular  viscus.  On  the  other  hand,  the  symptoms  may  be 
moderate  or  even  severe,  without  being  characteristic,  and  only 
by  direct  inspection  with  endoscopic  instruments  or  by  exploration 
be  accurately  diagnosed.  Escape  of  blood  from  a  hollow  viscus, 
even  when  abundant,  cannot  be  taken  as  positive  proof  that  ulcer 
exists,  especially  when  the  blood  appears  without  a  corroborative 
symptomatology  or  history.  So,  in  certain  conditions,  an  essen- 
tial hematuria  may  occur  or  hematuria  complicating  a  general 
disease,  such  as  malaria,  without  the  presence  of  lesions  in  the 
mucous  membrane  of  the  genito-urinary  tract,  and  melena  with  ho 
discoverable  ulcer  of  the  alimentary  tract  is  seen  at  times  in  obstruc- 
tion to  the  portal  circulation.  An  ulcer  situated  in  any  hollow 
viscus  may  gradually  extend  in  depth  until  it  perforates  or  so 
weakens  the  wall  that  it  cannot  withstand  the  necessary  intra- 
visceral  pressure.  The  outcome  in  such  cases  depends  on  the  space 
into  which  the  rupture  occurs,  and  on  the  presence  or  absence  of 
adhesions  on  the  serous  surface,  which,  if  sufficient,  may  prevent 
escape  of  visceral  contents  or  limit  them  to  a  restricted  field  and 
render  the  accident  comparatively  harmless. 

Gastric  and  Duodenal  Ulcer. — Simple  ulcer  of  the  stomach, 
known  also  as  round  ulcer  of  the  stomach,  chronic  ulcer  of  the 
stomach,  or  ulcus  ex  digestione,  occurs  with  great  frequency  (ulcer 
of  the  stomach  was  found  in  4.4  per  cent,  of  59,000  autopsies),  and 


ULCER  213 

depends  for  its  etiology  upon  the  digestive  action  of  stomach  secre- 
tions upon  the  mucous,  muscular,  and  peritoneal  layers  of  the  gastric 
wall  after  their  vitality  has  been  reduced  by  vascular  disease,  as  ar- 
t  eri<  isclerosis,  necrosis,  hyaline  degeneration,  and  fatty  degeneration 
of  the  intima,  by  thrombosis,  hemorrhage  from  passive ' conges- 
tion.  or  infarction.  Gastric  ulcer  also  appears  in  cases  of  chlorosis, 
in  which  the  alkaline  element  of  the  blood  is  subnormal  and  in 
patients  who  have  received  severe  burns,  regardless  of  the  part 
of  t  he  body  affected.  There  can  be  no  doubt  that  traumatism  and 
the  ingestion  of  substances  which,  by  their  heat  or  their  chemic 
action,  impair  the  vitality  of  the  mucosa  serve  as  causes  favoring 
the  destructive  action  of  the  digestive  fluids.  The  exact  value  of 
infection  as  a  cause  has  not  been  satisfactorily  determined,  but  it 
seems  certain  that  many  gastric  ulcers  occur  without  the  assist- 
ance of  bacteria,  for  the  stomach  has  the  power  of  autosterilization, 
and  the  frequent  excess  of  HC1  in  ulcer  cases  favors  this  function. 

The  sites  of  predilection  are  the  small  curvature,  the  posterior 
wall,  and  the  pyloric  end;  however,  they  may  occur  on  any  surface 
which  comes  in  contact  with  gastric  juice.  Gastric  ulcers  vary  hi 
si/e,  from  a  diameter  of  $  to  3  or  4  inches,  and  in  depth  from  a  super- 
ficial destruction  of  the  mucosa  to  complete  destruction  of  all  the 
coats  of  the  stomach  wall.  The  surface  of  the  ulcer  varies  with 
its  age.  At  the  beginning  it  is  brown  or  dirty  brown,  and  later 
becomes  clean  and  smooth,  showing  the  structures  of  the  stomach 
coats.  The  ulcers  are,  if  deep,  terraced  or  funnel-shaped  and  are 
larger  at  the  mucosa.  If  the  ulcer  is  recent  the  tissues  surround- 
ing it  are  soft,  but  when  chronic,  the  base  and  edges  are  infiltrated, 
and  may  show  an  abundance  of  cicatricial  tissue,  which  draws  the 
surrounding  wall  into  various  abnormal  shapes;  in  this  way  the 
hour-glass  stomach  is  produced.  The  ulcer  is  usually  round  or 
oval.  There  may  be  several  and  coalescence  occurs  occasionally. 
The  ulcer  may  be  situated  at  the  pylorus,  one  wing  lying  in  the 
stomach  the  other  in  the  duodenum  (saddle  ulcer). 

The  presence  of  gastric  ulcer  may  cause  no  symptoms  and 
be  recognized  only  postmortem,  or  when  an  accident,  like  perfora- 
tion or  hemorrhage,  takes  place.  On  the  other  hand,  it  may  pro- 
duce typic  symptoms  of  pain  after  eating,  when  gastric  acidity 
is  highest,  amelioration  by  additional  food,  vomiting,  tenderness, 
and  hemorrluige,  often  occult,  in  the  stomach  contents  or  stools. 
The  presence  of  excessive  hydrochloric  acid  often  accompanies 
ulcer:  likewise  it  often  appears  in  the  absence  of  ulcer;  and  the 
total  acidity  may  be  subnormal  in  tlu>  presence  of  ulcer.  It  is  an 
unreliable  sign.  Blood  in  the  stomach  contents  is  perhaps  the  most 
important  clinical  finding.  In  all  cases  of  gastric  ulcer  albumin 
should  be  found  in  the  stomach  contents;  use  lavage  at  evening; 


214  PRINCIPLES   OF   SURGERY 

allow  no  food  over  night;  recover  the  stomach  contents  the  fol- 
lowing morning  before  food  or  drink  is  taken;  albumin  should  be 
present.  Examination  of  the  stools  for  blood  should  be  done  only 
after  elimination  of  ingested  blood  and  hemoglobin;  purge  with 
castor  oil;  afterward  give  no  food  which  could  contain  blood  or 
hemoglobin  even  hi  minute  quantities;  examine  stools  at  the  end 
of  twenty-four  hours.  If  blood  is  discovered,  it  is  certain  to  have 
come  from  the  alimentary  tract. 

Acute  Ulcer. — Acute  gastric  ulcers  are  much  less  frequent  than 
chronic.  They  are  usually  small.  They  may  develop  rapidly  and 
even  cause  perforation  within  a  few  days. 

Complications  and  Sequelce. — The  complications  and  sequelae  of 
gastric  ulcer  are  grave.  Pyloric  obstruction,  hour-glass  stomach, 
adhesions,  perforation,  and  perigastric  abscess  are  the  most  im- 
portant. Cancer  of  the  stomach  frequently,  if,  indeed,  not  in  the 
vast  majority  of  cases,  originates  either  in  an  ulcer  or  in  the  cica- 
trix  left  by  healing  of  an  ulcer. 

Duodenal  Ulcer. — This  ulcer  is  closely  allied  to  gastric  ulcer; 
it  is  similar  in  type  and  in  etiology.  It  is  always  situated  hi  the 
upper  part  of  the  duodenum,  that  part  being  closest  of  kin  to  the 
stomach,  and  is  rarely  seen  more  than  1|  or  2  inches  below  the 
pylorus.  It  is  more  frequent  hi  men.  It  is  oftenest  seen  in  adults, 
but  has  been  observed  hi  the  newborn.  Its  symptomatology  is 
not  so  clear  and  definite  as  that  of  gastric  ulcer.  There  is  usually  a 
history  of  recurrent  attacks.  Pain  and  discomfort  after  eating, 
long  enough  afterward  for  digestion  to  be  well  under  way,  and 
hunger  pain,  relieved  by  taking  of  food  (these  patients  frequently 
take  a  biscuit  to  bed  with  them),  tenderness,  and  blood  in  the  stools 
are  the  diagnostic  symptoms.  Examination  of  gastric  contents  is 
of  little  value.  Duodenal  is  much  less  frequent  than  gastric  ulcer, 
and  far  less  likely  to  be  followed  by  carcinoma.  Often  the  first 
evidence  of  duodenal  ulcer  (in  half  the  cases,  according  to  Wanach) 
is  perforative  peritonitis.  Perforation  occurs  much  more  often  on 
the  anterior  than  on  the  posterior  surface. 

Treatment  of  Gastric  and  Duodenal  Ulcers. — The  treatment  of 
gastric  and  duodenal  ulcers  may  be  subdivided  into  the  treatment 
of  the  ulcer  as  such  and  of  the  complications.  The  treatment  of 
ulcer  is  either  medicinal  or  surgical.  It  must  be  understood  that 
the  ulcers  cannot  be  dealt  with  as  those  that  can  be  treated  under 
direct  vision  and  have  topical  remedies  applied. 

Medical  or  non-operative  treatment  is  carried  out  by  a  strict 
regimen  of  diet  of  fluid  or  semifluid  character,  rest  hi  bed,  neutrali- 
zation of  acid  secretions,  if  they  are  present  hi  sufficient  quantities 
to  demand  it,  withholding  the  food  substances  from  which  hydro- 
chloric acid  is  derived,  particularly  sodium  chlorid,  and  the  ad- 


ULCER  215 

ministration  of  such  drugs  as  by  experience  have  shown  themselves 
m<»t  efficacious.  Of  these  drugs,  nitrate  of  silver  and  bismuth 
>ul initiate  head  the  list.  Gastric  lavage  is  of  questionable  value 
ami  is  capable  of  positive  harm.  Such  a  regimen  may  be  followed 
faithfully  for  six  or  eight  weeks,  and,  if  marked  improvement  or 
cure  does  not  result,  surgical  treatment  should  be  done.  If,  after 
apparent  cure,  recurrence  takes  place  the  case  becomes  surgical. 

All  ca>e-  of  recurrent  ulcer,  all  cases  not  responding  to  internal 
treatment  as  outlined  above,  all  cases  showing  evidence  of  such 
complications  as  abundant  hemorrhage,  protracted  or  frequently 
repeated,  so  that  emaciation  and  anemia  result,  all  cases  showing 
-u>picion  of  malignant  change,  all  cases  producing  obstructive 
symptoms  or  evidence  of  hour-glass  contraction,  adhesions,  or 
perforation  admit  of  no  question — they  are  surgical  cases. 

The  surgical  treatment  of  gastric  and  duodenal  ulcer  may  deal 
directly  with  the  ulcer  by  excision,  if  its  size  and  location  admit, 
and  t  hi-  is  the  ideal  treatment.  If  this  cannot  be  done  with  safety, 
the  M-cond  best  treatment  is  drainage  of  the  stomach  and  shutting 
t  he  food  from  its  normal  course,  so  that  it  comes  as  little  as  possible, 
or  not  at  all,  into  contact  with  the  ulcer  surface.  This  is  ac- 
complished by  gastrojejunostomy  or  an  equivalent,  with  such 
additional  measures  as  will  guarantee  that  the  artificial  opening 
shall  remain  patent,  and  that  the  food  shall  continue  to  pass 
through  it  rather  than  per  viam  naiuralem.  Furthermore,  it  is 
HIM  ,  where  possible,  to  infold  the  ulcer  from  the  peritoneal  sur- 
a  protection  against  postoperative  perforation  or  hemorrhage 
and  a  guarantee  of  early  healing. 

In  a  few  cases  of  gastro-enterostomy  recurrence  of  the  ulcer 
takes  place  at  the  new  opening  or  in  the  small  intestine,  which  is 
directly  exposed  to  the  acidulated,  peptonizing  contents  of  the 
Momach. 

Ulcers  of  Anus,  Rectum,  and  Sigmoid  Colon.— Ulcers  are  very 
frequent  in  the  terminal  portion  of  the  alimentary  tract  and  are  of 
many  varieties. 

1'Anilinjif. — The  etiology  of  ulcers  of  the  terminal  segments  of  the 
alimentary  tract  is  identical  in  nature  with  the  causes  of  ulceration 
eUewhere.  Trauma,  imperfect  circulation,  infection,  and  consti- 
tutional depravity  are  the  underlying  factors  which  result  in  ulcera- 
tion. This  portion  of  the  alimentary  tract  is  constantly  subjected 
to  anatomic,  physiologic,  and  accidental  conditions  which  favor 
the  development  of  ulcers,  and  in  consequence  ulcers  are  found 
here  perhap-  with  greater  frequency  than  in  any  other  equal  areas 
of  the  liody. 

I'lcers  of  the  anus  are  either  -imple  or  specific,  and  their 
nee  i-  -ugLre-ted  I .y  pain  or  defecation,  purulent  discharge, 


216 


PRINCIPLES    OF   SURGERY 


and  frequently  by  dysuria.  They  are  difficult  to  relieve,  owing  to 
the  necessary  function  and  the  continual  infection.  Syphilis  and 
tuberculosis  must  always  be  eliminated. 

Treatment. — The  treatment  of  these  ulcers  is  rest,  divulsion,  or 
incision  of  the  sphincter,  maintenance  of  soft  or  semiliquid  stools, 
cleanliness  and  the  application  of  stimulating  dressing,  such  as 
ichthyol  or  balsam  of  Peru,  diluted  with  3  parts  of  castor  oil, 
and  the  application  of  silver  nitrate  or  carbolic  acid  from  time  to 

time.  If  the  two  last  drugs  are 
used  full  strength  their  applica- 
tion should  not  be  frequent. 
In  case  of  failure  by  the  above 
course,  excision  and  immediate 
suture  should  be  done,  or  an  in- 
cision should  be  made  partially 
or  entirely  through  the  external 
sphincter  ani  and  healing  from 
the  bottom  of  the  incision  en- 
couraged. 

Ulcers  of  the  rectum  and 
sigmoid  are  simple,  specific,  or 
secondary  to  constitutional  dis- 
orders. 

The  simple  ulcers  are  due  to 
trauma,  to  venous  stagnation, 
as  in  varicose  veins,  hemor- 
rhoids or  portal  obstruction,  or 
inflammatory  conditions  such 
as  result  from  follicular  or  ca- 
tarrhal  proctitis  and  from  stric- 
tures. In  the  latter  condition 
the  ulcer,  of  course,  may  de- 
pend on  the  cause  of  the  stric- 
ture, result  from  disintegration 

of  the  fibrous  tissue  or  from  an  inflammatory  condition,  for 
which  in  its  turn  the  stricture  is  responsible. 

The  specific  ulcers  are  syphilitic  (rarely  chancroidal  or  gonor- 
rheal),  tubercular,  diphtheric,  or  dysenteric  (amebic  or  bacillary), 
and  occasionally  typhoidal.  The  recognition  of  these  ulcers,  aside 
from  any  characteristic  appearance,  may  be  determined  by  the  dis- 
covery of  the  causative  micro-organism,  or  by  their  association 
with  other  evidences  of  the  causative  infection. 

The  constitutional  conditions  favoring  ulceration  of  the  rectum 
and  sigmoid  are  diabetes  mellitus,  nephritis,  general  debility,  and 
malnutrition. 


Fig.  37. — Enormous   tubercular  ulcer 
surrounding  the  anus. 


ULCER  217 

Malignant  tumors  of  these  parts  frequently  degenerate,  ulcer- 
ate, and  bleed  as  in  other  parts  of  the  body. 

The  Symptoms  of  Rectal  and  Sigmoidal  Ulcers. — -The  motions 
arc  abnormal.  They  contain  pus  or  blood  or  mucus,  or  an  admix- 
ture <>f  these;  diarrhea  is  present  and  persists;  it  is  worse  during 
waking  hours,  when  the  patient  is  up;  there  are  frequently  no  mo- 
tion- over  night,  but  first  thing  on  arising  there  is  a  call  to  stool, 
tin-  so-called  morning  diarrhea,  and  the  motion  is  not  natural  in 
appearance.  If  the  ulcers  are  not  situated  close  to  the  sphincter 
there  will,  as  a  rule,  be  little  or  no  discomfort  beyond  a  heaviness 
or  dull  ache  in  the  lower  part  of  the  back,  but  when  located  at  the 
internal  sphincter  ulceration  causes  marked  local  and  reflex 
symptoms,  and  even  remote  symptoms  may  be  attributable  directly 
to  this  cause;  these  patients  are  nervous  and  irritable.  Ulcers  in 
the  lower  end  of  the  rectum  and  in  the  anus  often  produce  symptoms 
referable  to  the  genito-urinary  apparatus. 

Treatment. — The  treatment  of  ulcers  of  the  rectum  and  sigmoid 
depends  on  the  underlying  condition.  If  this  condition  is  remov- 
able the  ulcers  may  be  cured.  If  the  causative  condition  cannot 
be  removed  the  ulcers  are  more  difficult  to  remove  and  the  cure 
more  uncertain  in  its  permanence.  In  such  hopeless  conditions 
as  advanced  diabetes  and  nephritis  cure  is  often  impossible,  but 
in  the  milder  cases  there  is  more  hope. 

The  first  step  is  removal  of  the  cause  or  its  correction  as  far 
a-  possible.  Second,  correction  of  the  diet  and  the  withdrawal 
of  all  foods  that  may  irritate  the  ulcerated  area.  Highly  seasoned 
ft  ><  »<  Is  are  contra-indicated.  The  ulcers  themselves  may  be  treated 
by  direct  application  through  the  speculum  or  by  injections. 
\Veak  solutions  of  nitrate  of  silver,  iodoform  (5  to  10  per  cent.)  in 
olive  oil,  and  20  per  cent,  aqueous  fluidextract  of  krameria  in 
water  are  among  the  most  useful.  In  ulceration  caused  by  amebic 
dy-entery  many  drugs  are  favorites  with  different  authors.  Solu- 
tion- of  quinin.  cold  water,  antiseptics,  as  formaldehyd,  1  :  6000  to 
1  :  10,000,  and  sulphocarbolate  of  copper,  1  :  5000,  are  the  most 
important.  These  often  fail  to  cure,  and  appendicbstomy  is  done 
to  facilitate  colonic  irrigation  and  bring  the  solutions  into  direct 
nmtact  with  the  ulcers.  Emetin  hypodermically  has  recently 
been  proved  curative  in  nearly  all  cases. 

In  all  cases  of  ulceration  the  mucous  membrane  of  the  intestines 
should  be  cleansed  by  enema  before  administration  of  treatment. 


CHAPTER  IX 
SINUS  AND  FISTULA 

Sinus. — Sinus  is  an  abnormal  opening  leading  from  a  tegu- 
mentary  surface  into  the  tissues,  and  is  blind  at  its  deep  ending. 
It  may  lead  from  any  surface,  but  it  never  leads  from  one  surface  to 
another. 

Fistula. — Fistula  is  an  abnormal  opening  leading  from  one 
tegumentary  surface  through  the  tissues  to  another.  It  is  open  at 
each  end,  and  forms  a  communication  between  the  two  surfaces, 
and  allows  the  contents  found  on  these  surfaces  to  pass  through 
the  opening  onto  the  other  surface.  Fistula  may  connect  a  cuta- 
neous with  a  mucous  surface,  as  is  seen  in  fecal  fistula,  in  which  the 
canal  leads  from  the  gut  through  the  abdominal  wall  to  the  skin, 
or  it  may  connect  two  mucous  surfaces,  as  is  illustrated  by  com- 
munication between  the  rectum  and  the  urinary  bladder. 

The  only  exception  to  the  above  definition  is  found  in  fistula  in 
ano.  Both  sinuses  and  fistulae  pass  here  under  the  name  of  fistula. 
A  sinus  leading  from  the  skin  upward  toward  the  mucous  membrane 
of  the  gut,  but  not  perforating  it,  is  called  blind  external  fistula,  and 
one  leading  from  the  anal  or  lower  rectal  lining  out  into  the  sur- 
rounding tissue,  but  not  through  the  skin,  is  called  blind  internal 
fistula. 

Etiology. — In  every  case  of  fistula  and  sinus  there  must  be  an 
establishing  or  creative  cause  and  a  maintaining  cause.  Sinus 
is  caused  either  by  a  wound  or  by  the  discharge  of  pathologic 
contents  which  have  accumulated  in  the  tissues,  causing  an  open- 
ing, such  as  happens  when  an  abscess  ruptures.  It  is  maintained 
by  the  continued  discharge  from  a  persistent  focus  situated  at  its 
inner  extremity.  This  focus  may  be  a  buried  suture  or  ligature 
(usually  non-absorbable,  otherwise  the  sinus  will  not  persist  long), 
a  mass  of  necrotic  or  carious  bone,  or  some  specific  infection, 
usually  tuberculous. 

If  the  discharge  is  small  in  quantity  or  variable  the  sinus  may 
close  from  time  to  time,  and  reaccumulation  causes  reopening  of 
the  abnormal  canal. 

Congenital  sinuses  are  those  resulting  from  failure  to  close 
of  certain  ducts  and  clefts  belonging  to  fetal  life.  The  foramen 
cecum  of  the  dorsal  surface  of  the  tongue  is  a  constant  example 

218 


SINUS    AND    FISTULA 


219 


of  this,  and  another,  of  not  infrequent  occurrence,  is  situated  in 
the  median  line  just  posterior  to  the  anal  outlet,  and  leads  upward 
ami  backward  over  the  dorsal  surface  of  the  coccyx.  These  are 
lined  with  epithelium  and  need  not  concern  us  further  here  (see 
Inclusion  Cysts). 

Fistulse  are  established  by  the  production  of  a  communication 
between  two  surfaces.  The  cause  may  be  traumatic,  as  in  cases 
whrrr  the  bladder  is  punctured  through  the  rectum,  or  where  an 
ii iij  cictcd  fetal  head  causes  necrosis  of  the  tissues  separating  the 
cavity  of  the  bladder  from  the  vagina,  by  pathologic  conditions, 
as  seen  in  adhesion  between  the  serous  surfaces  of  two  hollow  organs, 


Fig.  38. — Congenital  sinus  over  coccyx  (vide  Inclusion  Cysts). 

and  the  extension  of  an  ulcer  or  a  rupture  from  one  into  the  other; 
or  by  the  rupture  of  an  abscess  in  two  directions,  or  by  operative 
means  where,  by  accident  or  purposely,  such  a  communication  is 
made.  The  maintaining  cause  of  fistula  is  the  passage  of  normal 
secretion-  ami  excretions  through  the  canal,  or  the  presence  of 
condition-,  such  as  tubercular  infection  in  t he  walls  of  the  canal,  or 
the  pre-ence  of  foreign  material  along  the  course  of  the  fistula,  and 
the  discharge  of  pu-  and  serum  through  two  openings.  The  last- 
named  condition  is  the  equivalent  of  two  sinuses  leading  to  the 
same  point  and  communicating  with  each  other,  one  from  one  tegu- 
mentary  surface,  the  other  from  another.  Fistulse  may  be  main- 


220  PRINCIPLES    OF   SURGERY 

tained  by  the  lumen  of  the  canal  becoming  lined  with  epithelium 
which  extends  from  each  surface.  The  fistula  has  healed  open  and, 
instead  of  the  raw  ulcerous  surface,  there  is  normal  new-formed 
epithelial  covering.  Such  fistulae  are  permanent — i.  e.,  they  would 
not  heal  even  if  the  contents  were  no  longer  permitted  to  pass 
through.  This  is  the  type  of  fistula  artificially  created  in  such 
operations  as  gastro-enterostomy  and  cholecystenterostomy.  The 
closer  the  two  surfaces  connected  by  the  fistula  are  to  each  other, 
the  more  probable  it  is  to  be  lined  with  epithelium  and  the  sooner 
the  lining  will  form. 

Pathology. — If  we  consider  that  an  ulcer  is  a  more  or  less  flat 
concave  lesion,  and  that  fistula  and  sinus  are  tubular,  there  is  no 
pathologic  distinction.  There  is  a  fibrous  tissue  base  of  new  for- 
mation surrounding  the  canal.  This  scar-tissue,  just  as  in  chronic 
ulcer,  may  interfere  with  healing,  especially  if  a  tubercular  or 
syphilitic  infection  is  present.  The  surface  of  the  lumen  may  be 
covered  with  granulation  tissue,  completely,  partially,  or  not  at 
all.  The  areas  not  covered  with  granulations  show  necrotic  tissue. 
Sinuses  present  at  times  a  peculiar  aspect  at  their  opening  into  the 
integument  if  they  are  chronic  and  persistently  open.  The  con- 
nective tissue  contracts  around  the  lumen,  and  the  granulations, 
often  unhealthy  or  hypertrophic,  protrude  in  circular  form  around 
the  opening.  This  has  been  named  hen's  anus  sinus,  and  is  usually 
seen  in  sinuses  associated  with  chronic  bone  infections. 

Diagnosis. — In  the  first  place,  it  is  necessary  to  determine  the 
presence  of  fistula  or  sinus,  and  which  of  the  two  is  present.  The 
position  of  the  opening  may  of  itself  determine  which  is  present; 
on  the  other  hand,  the  position  might  point  equally  to  the  two  con- 
ditions. If  by  passing  a  probe  into  the  canal  it  can  be  made  to 
pass  through  the  deeper  end  of  the  canal  on  to  a  surface  or  into  a 
normal  cavity,  the  question  is  settled.  But  the  devious  routes 
of  the  canals  often  render  it  impossible  to  follow  them  to  their 
terminus,  or  the  site  of  that  terminus  may  be  so  situated  as  to  pre- 
clude the  possibility  of  recognizing  such  a  passage,  as  would  be  ex- 
pected from  a  known  pathologic  process  which  would  indicate 
sinus;  but  in  those  cases  where  the  opening  is  small,  and  the  normal 
contents  of  the  cavity  hard  and  too  large  to  pass,  only  such  fluids 
as  might  escape  through  the  lumen  under  normal  circumstances,  as 
in  diarrhea  in  the  instance  cited,  and  the  discharge  from  the  mouth 
of  the  fistulous  lumen  would  appear,  and  hence  differentiation  by 
this  means  is  impossible.  The  passage  of  the  contents  of  normal 
cavities  through  the  normal  or  abnormal  outlets  of  other  organs  is 
positive  proof  of  fistula,  as  of  passage  of  feces  hi  the  urine  or  urine 
by  the  rectum.  This  may  occur  in  sufficient  quantity  to  cause 
very  distressing  symptoms  without  the  surgeon  being  able  to 


SINUS    AND    FISTULA 


221 


prove  it  satisfactorily.  The  opening  should  be  searched  for,  then, 
by  endoscopic  methods,  if  they  can  be  applied;  it  is  wise,  when 
possible,  to  determine  the  exact  point  of  each  opening  of  a  fistula, 
unless  the  canal  is  necessarily  so  short  that  discovery  of  one  opening 
fixe-  approximately  the  site  of  the  other.  •  Even  with  this,  it  may 
still  be  impossible  positively  to  diagnosticate  fistula,  and  resort 
mu>t  be  had  to  the  very  simple  and  effective  injection  of  some 
harmless,  but  easily  recognized,  fluid  into  one  cavity  and  deter- 
mination of  its  passage  into  the  other  or  upon  the  surface.  Sweet 
milk,  solutions  of  potassium  permanganate,  or  of  methylene-blue 
an-  most  frequently  emplbyed.  Such  a  method  will  determine 
positively  that  fistula  is  present,  but,  unless  observation  can  be 
made  directly  of  its  passage,  it  gives  no  further  information.  The 
!>:i>-uge  of  normal  contents  of  one  cavity  through  the  outlet  of 


!9. — Tubercular  sinuses  of  hip.     Straws  show  direction  of  sinuses. 


another  may  be  uncertain,  and  yet  the  discovery  in  the  second 
cavity  or  its  outlet  of  a  pathologic  product  belonging  only  to  the 
former  give-  positive  information.  Thus,  I  was  able  to  ascertain 
the  presence  of  a  fistula  between  the  intestine  and  the  urinary 
bladder  of  a  young  girl  in  whom  there  was  no  proof  of  urine 
pa— ing  into  the  reel  urn  or  of  feces  through  the  urethra,  but  who 
di<covred  a  large  lumltricoid  worm  crawling  out  of  the  meatus 
urinarius. 

Sinuses  are  usually  found  opening  on  accessible  surfaces  of  the 
body.  Their  outlet  is  no  index  to  their  source  or  course  or  depth. 
The  route  may  be  very  short  and  direct  or  very  long  and  deviou-. 
so  that  occasionally  question  will  arise  as  to  what  and  where  the 
rau-ative  pathology  is.  A  complete  history  should  be  obtained, 


222  PRINCIPLES   OF   SURGERY 

and  such  evidence  as  scars  and  abnormal  structures,  previous 
operations  with  buried  non-absorbable  sutures,  should  be  taken  into 
account.  No  assurance  can  be  placed  upon  the  stoppage  of  the 
probe  unless  by  it  a  pathologic  process  or  a  foreign  body  can  be 
located.  Occasionally  multiple  sinuses  are  present,  and,  by  study- 
ing the  group,  more  accurate  information  may  be  gained.  Injec- 
tion of  the  sinus  with  bismuth  paste  (Beck's)  until  the  cavity  is 
filled,  and  subsequent  skiagraphy  of  the  part,  gives  most  satis- 
factory evidence,  as  by  this  means  the  course  and  length  and 
ramifications  of  the  channel  as  well  as  a  certain  amount  of 
evidence,  positive  or  negative,  of  the  underlying  condition  may 
be  determined.  So,  also,  the  nature  of  the  discharge  may  at 
times  help  materially  in  settling  the  nature  of  the  underlying 
lesion. 

Treatment  of  Sinus  and  Fistula. — Unless  the  pathologic  con- 
dition underlying  sinus  can  be  relieved  or  removed  the  sinus  is 
incurable.  If  by  delay  and  non-operative  treatment  there  is 
probability  that  the  causative  pathology  can  be  relieved,  or  that 
the  foreign  body  will  escape  through  the  opening,  it  is  better  to 
wait;  this  is  all  important  where  delay  is  not  dangerous,  but  where 
operation  for  radical  cure  is  attended  with  much  risk.  When  one 
does  not  know  the  definite  location  of  the  maintaining  cause  a 
sure  way  to  find  it  is  to  follow  the  sinus,  unless  its  course  renders 
such  a  procedure  impossible.  When  the  lesion  is  reached  it  is  to 
be  dealt  with  radically,  and  treated  subsequently  by  packing  and 
healing  by  second  intention,  or  if  possible — it  is  usually  not — 
the  whole  pathologic  tissue  may  be  removed  in  such  a  way  as  to 
get  primary  union.  The  fibrous  tissue  and  unhealthy  surface  of 
the  sinus  with  the  contracted  vent  must  be  curretted  or  dissected 
away.  This  should  be  done  habitually;  it  is  imperative  if  healing 
by  first  intention  is  desired. 

In  those  cases  where  delay  is  thought  advisable,  in  non-opera- 
tive cases,  and  in  all  cases  where  operation  would  be  dangerous  or 
mutilating,  and  in  all  where  no  great  amount  of  diseased  tissue  is 
suspected,  it  is  advisable  to  inject  Beck's  bismuth  paste  into  the 
sinus,  as  many  cases  are  permanently  cured  by  this  method,  par- 
ticularly tuberculous  sinuses.  The  fact  that  a  sinus  has  continued 
long,  even  though  for  years,  is  not  a  centra-indication,  for  the 
incredible  results  from  employment  of  this  method  demand  almost 
that  it  be  employed  prior  to  undertaking  operative  treatment. 
Beck's  paste  is  made  according  to  two  formulae: 

Formula  for  skiagraphy  and  early  treatment: 

Bismuth  subnitrate 30  parts. 

Vaseline  alb 60  parts. 

M.  et  ft.  unguent um. 


SINUS    AND    FISTULA  223 

Formula  for  late  treatment: 

Bisuiut  h  subnitrate 30  parts. 

Vaseline  alb 60  parts. 

Paraffin  inollis 5  parts. 

Cene 5  parts. 

M    1 1  ft.  unguentum. 

It  is  evident  from  the  formulae  that  the  latter  forms  a  harder 
paste.  Some  surgeons  prefer  to  use  the  first  formula  for  all  cases, 
with  apparently  good  reasons,  and  some  reduce  the  quantity  of 
bismuth — bismuth  30  to  40  parts,  vaselin  100  parts — and  substi- 
tute the  subcarbonate  of  bismuth  for  the  subnitrate  recommended 
by  Beck,  as  the  subcarbonate  is  less  toxic. 

When  this  treatment  is  contra-indicated,  and  at  what  stage  in 
the  course  of  the  disease  it  is  best  to  employ  it,  are  two  important 
ami  as  yet  not  thoroughly  settled  questions.  It  can  hardly  be 
claimed  that  the  method  is  contra-indicated  in  any  case,  but  there 
are  necessary'  precautions'  and  modifications.  If  there  is  a  large 
amount  of  purulent  discharge,  or  if  the  patient  shows  poor  vitality, 
it  is  necessary  to  reduce  the  discharge  and  build  up  the  general 
vitality  before  making  a  large  injection,  but  small  quantities  of  the 
paste  may  be  used  with  safety,  often  with  advantage,  and,  when 
improvement  is  sufficient,  larger  quantities  can  be  used.  The 
iuo-t  favorable  cases  are  those  in  which  the  discharge  is  not  puru- 
lent or  but  slightly  so.  The  cases  showing  the  greatest  percentage 
of  failure  are  advanced  cases  of  bone  and  joint  tuberculosis  (spon- 
dylitis  and  coxitis).  The  secretions  should  be  sucked  from  the 
sinus  by  cupping  before  injection  is  made.  If  the  sinus  bleeds, 
postpone  the  injection  for  twenty-four  to  forty-eight  hours. 

The  paste  must  be  warm  enough  to  be  forced  easily  through  a 
gla~s  syringe.  A  catheter  of  suitable  size  is  inserted  to  the  bottom 
of  the  sinus  and  the  deposit  made  through  the  catheter,  filling  the 
cavity  from  within  outward.  If  the  cavity  is  large  it  is  better 
not  to  attempt  too  large  a  dose,  but  to  employ  safe  dosage  (10  to  30 
c.c.)  and  repeat  at  a  future  sitting.  It  is  preferable  that  the  sinus 
should  he  filled  with  paste,  as  will  be  indicated  by  complaint  of 
pain  by  the  patient,  but  an  excessive  quantity  should  not  be 
attempted.  After  a  satisfactory  injection  one  may  wait  for  ten 
to  twenty  days  before  making  a  second,  or,  if  there  is  evidence  that 
the  paste  has  largely  escaped,  it  may  be  repeated  in  a  few  days. 

Bier's  hyperemic  treatment  may  be  used  with  advantage  in 

when-  its  application  is  possible,  but  if  the  real  lesion  is 

far  removed  from  the  mouth  of  the  sinus  cupping  can  be  of  little 

advantage,  and  if  the  lesion  is  not  situated  on  an  extremity  hyper- 

emia  cannot   be  produced  by  the  tourniquet. 


224  PRINCIPLES   OF   SURGERY 

Treatment  of  Fistula. — The  methods  of  treating  fistula  are 
very  simple,  but  their  successful  performance  is  one  of  the  most  diffi- 
cult tasks  of  the  surgeon,  often  followed  by  failure,  while  a  few 
present  hopeless  defects.  The  treatment  of  fistula  may  be  classed 
as  follows:  (1)  Direction  of  the  maintaining  cause  through  other 
normal  or  artificial  channels.  (2)  Excision  of  the  fistulous  tract 
and  suture.  (3)  Removal  of  the  structure  from  which  the  secretion 
enters  the  fistula.  (4)  Slitting  up  the  fistula.  (5)  Duct  trans- 
plantation. 

(1)  In  case  a  fistula  is  of  small  caliber  and  not  healed  open,  if 
the  tissues  are  healthy,  cure  may  usually  be  accomplished  by 
prevention  of  the  passage  of  substances  through  the  opening. 
This  presupposes  that  all  obstruction  to  the  exit  of  normal  con- 
tents of  the  viscus  shall  be  removed,  and  that  no  accumulation  of 
normal  contents  be  allowed  to  distend  the  viscus,  or  that  the  same 
end  shall  be  accompanied  by  the  creation  of  an  abnormal  vent  at  a 
more  favorable  site.     If  the  fistula  has  previously  healed  open,  or  if 
a  large  amount  of  scar  tissue  surrounds  the  tract,  failure  results. 
As  an  illustration,  take  a  fistula  leading  from  the  bladder  to  the 
skin  of  the  abdomen.     When  the  urethral  obstruction,  usually 
stricture,  is  removed  and  a  self-retaining  catheter  is  introduced,  or 
when  a  perineal  cystotomy  or  external  urethrotomy  is  done  and  a 
drainage-tube  placed  in  the  bladder,  the  fistula  should  heal. 

(2)  In  other  instances  it  is  necessary  to  excise  the  fistulous  canal 
and  all  surrounding  scar  tissue  and  suture.    This  is  necessary  in  all 
cases  of  fistula  that  heal  open.     If  there  is  no  scar  tissue,  excision 
may  be  unnecessary;  however,  the  edges  should  be  scraped  down 
to  healthy  tissue.     This  method  depends  very  largely  for  its  suc- 
cess upon  primary  union,  at  least  of  the  rent  in  that  viscus  from 
which   the  leakage  occurs.      If  two  communicating  surfaces  lie 
close  together  their  walls  must  be  dissected  away  from  each  other, 
so  that  they  may  be  closed  independently;  it  is  preferable,  where 
possible,  to  close  the  opening  in  one  in  a  direction  at  right  angles 
to  the  line  of  closure  in  the  other.     In  all  instances  the  dissection 
should  be  extensive  enough  to  allow  the  edges  of  the  fistula  to  be 
approximated  without  tension,  as  tension  on  the  sutures  and  tying 
sutures  sufficiently  tight  to  cause  necrosis  of  the  tissue  within  their 
grasp  is  a  certain  cause  of  failure.     A  viscus  cannot  be  permitted 
to  functionate  until  after  healing  occurs,  as  it  makes  traction  on 
sutures,  forces  contents  through  the  line  of  union,  and  carries  or 
favors  infection.      So  in  vesicovaginal  fistula  the  edges  are  fresh- 
ened, the  two  walls  dissected  apart,  each  sutured  independently 
of  the  other,  and  catheterization  done  at  regular  intervals  of  a  few 
hours  or  continuously. 

(3)  In  case  the  fistula  is  so  situated  that  it  cannot  be  relieved 


SINUS   AND    FISTULA  225 

l>y  other  procedures,  or  the  structure  from  which  the  discharge 
(oint>  i-  incapable  of  further  useful  function,  it  may  become  neces- 
.-.-iry  to  remove  the  structure  responsible  for  maintenance  of  the 
fistula.  For  example,  fistula  from  the  parotid  gland  or  from  ob- 
struction of  Stenson's  duct,  and  gall-bladder  fistula  due  to  per- 
manent obstruction  of  the  cystic  duct,  may  require  to  be  treated 
by  excision  of  the  structure  named. 

(4)  Certain  fistulse  are  situated  so  that  they  can  be  treated 
by  slitting  the  whole  canal  open,  thus  converting  it  into  an  incised 
wound,  removal  of  all  the  diseased  tissue  as  well  as  the  cicatricial 
ti<>ue,  and  packing  the  wound  open  so  as  to  get  healing  by  second 
intention,  or,  more  exceptionally,  suturing  for  primary  union. 
An  absolute  essential  in  this  class  of  cases  is  that  the  whole  of  the 
tistulous  tract,  with  all  ramifications,  however  minute,  shall  be 
<li-n»Yered  and  slit  open.     This  is  the  usual  treatment  of  the  most 
frequent  form  of  fistula,  namely,  fistula  in  ano. 

(5)  In  all  cases  of  duct  fistula  the  plan  of  transplantation  of  the 
<luet  may  be  done,  provided  the  duct  is  of  sufficient  length  to 
admit  of  such  a  method.     So  in  case  of  a  ureteral  fistula  the 
<lu  it  may  be  transplanted  into  the  bladder  at  a  favorable  point  or 
into  the  rectum,  and  in  fistula  of  Stenson's  duct  either  the  duct 
may  be  transplanted  or  a  new  duct  made  by  infolding  buccal  mu- 
<-<>u-  membrane. 

15 


CHAPTER  X 
ERYSIPELAS 

ERYSIPELAS  is  an  acute  inflammation  of  the  lymphatic  struc- 
tures of  the  skin  and  mucous  membrane  produced  by  streptococcus 
infection,  and  characterized  by  its  rapid  onset,  marked  constitu- 
tional symptoms,  abrupt  delimitation  of  the  inflamed  areas,  and  its 
tendency  to  recurrence. 

Etiology. — The  cause  of  erysipelas  has  been  given  until  recently 
as  the  Streptococcus  erysipelatis  of  Fehleisen.  Recent  investiga- 
tions do  not  confirm  the  older  belief  that  erysipelas  is  produced  by 
a  specific  streptococcus,  but  show  rather  that  the  disease  may  be 
produced  by  ordinary  pyogenic  streptococci,  whose  behavior  and 
virulence  vary,  and  which  may  produce  pus  or  not  according  to  their 
peptonizing  power,  which,  in  general,  does  not  equal  that  of 
pyogenic  staphylococci.  Streptococci  soon  lose  their  vitality  in 
cultures,  but  are  preserved  by  cold. 

Reduced  vitality,  anemia  and  exhaustive  diseases,  severe 
trauma,  and  hemorrhage  predispose  to  erysipelas.  The  universal 
distribution  of  streptococci  renders  infection  easy,  and  it  is  sur- 
prising that  erysipelas  is  not  more  common  than  it  is.  The  fact 
that  an  individual  is  suffering  from  other  streptococcic  infections 
or  has  erysipelas  does  not  afford  immunity,  but  seems  rather  to 
predispose  to  erysipelas. 

Atria. — Erysipelas  always  follows  the  introduction  of  strep- 
tococci through  an  atrium.  The  atrium  may  be  so  slight  as  to 
escape  the  notice  of  the  patient,  or  concealed  so  that  it  cannot  be 
easily  discovered,  whence  the  adoption  of  the  term  "idiopathic  ery- 
sipelas" of  the  older  writers.  Ulcers,  wounds,  abscesses,  sinuses 
and  fistulas,  hang-nails,  and  fissures  all  are  favorable  atria.  These 
may  be  situated  on  the  surface  or  may  be  on  the  mucous  mem- 
brane, especially  of  the  mouth  or  upper  air-passages,  a  fact  which 
explains  the  so-called  idiopathic  facial  erysipelas.  In  erysipelas 
neonatorum  the  bacteria  enter  at  the  unhealed  navel  of  the  new- 
born. Cases  develop  at  the  site  of  puncture  of  the  skin  when  as- 
pirating infected  cavities,  as  in  synovitis  and  pleuritic  effusions. 
The  genital  tract  of  the  parturient  woman  offers  an  especially 
inviting  field  for  streptococcus  infection,  and  consequently  one  of 
the  most  fatal  types  of  puerperal  sepsis  arises.  Although  ery- 
sipelas usually  appears  first  near  the  atrium,  the  inflammation  may 

226 


ERYSIPELAS  227 

be  remote  from  it;  it  may  be  conveyed  from  a  deep  focus  through 
the  blood  (hematogenous). 

Pathologic  Changes. — The  local  process  shows  the  usual 
•I"  an  acute  inflammatory  condition.  Streptococci  are 
found  in  great  numbers,  especially  in  the  lymph-spaces  and  small 
lymphatic  vessels  of  the  integument  and  the  subtegumentary  tis- 
sues. They  may  so  abound  as  actually  to  block  the  channels. 
Tht  bacteria  are  more  abundant  and  more  active  in  the  borders 
of  the  inflammation  and  are  fewer  or  entirely  absent  hi  the  older 
central  areas.  Minute  abscesses  may  be  present  in  great  numbers. 
Diapedesis  and  exudation  are  present,  the  latter  hi  great  measure 
in  the  regions  abounding  in  loose  cellular  tissue.  Occasionally 
bacteria  are  found  in  surrounding  uninflamed  tissue,  and  rarely  are 
recoverable  from  the  blood.  In  the  phlegmonous  type,  necrosis, 
especially  of  the  connective  tissue,  may  be  extensive,  and  pus  is 
found  with  or  without  mixed  infection.  Blebs  may  be  found 
over  the  inflamed  surface,  which  usually  contain  serum,  occa- 
sionally pus.  The  hair  may  fall  from  the  follicles  due  to  separa- 
tion from  the  papillae  by  cellular  infiltration.  There  is  a  greater 
proliferation  of  connective-tissue  cells  than  in  ordinary  infec- 
tions 

Local  Signs  and  Symptoms. — The  local  inflammation  may 
appear  either  before  or  subsequent  to  constitutional  symptoms. 
The  inflamed  area  shows  a  bright-red  color  and  rapidly  spreads  by 
continuity.  The  appearance  is  that  of  a  violent  inflammatory 
process.  The  most  distinctive  feature  of  this  inflammation  is 
that  it  terminates  abruptly;  there  is  no  shading  off  of  the  redness 
into  normal  tissue,  as  is  seen  in  ordinary  inflammations.  There 
may  be  red  streaks  over  the  larger  lymph-channels  leading  from 
the  affected  area  and  the  edges  of  the  inflamed  tissue  are  raised 
slightly,  but  perceptibly,  above  the  surrounding  level.  In  the 
central  part  the  swelling  may  be  so  great  as  to  render  a  small  sur- 
face anemic,  giving  it  a  whitish  or  yellowish-red  appearance.  Blebs 
may  form  on  the  surface  and  occasionally  are  numerous;  they  usu- 
ally contain  clear  serum,  but  at  times  pus.  When  "they  rupture, 
their  surface  may  become  dry  and  a  thin  scab  form.  As  the  in- 
flammatii.n  -ubsides  < lesquamation  takes  place,  and  now  and  then 
alt  »pecia  is  observed.  After  from  two  to  five  days  the  inflammation 
ih-ides  at  the  point  iir-t  affected,  but  may  extend  at  the  same 
time  into  the  surrounding  zones,  and  may,  before  recovery,  return 
the  site  of  the  beginning.  The  affected  area  i-  indurated.  This 
•n-ion  is  not  uniform  in  all  directions,  but  may  affect  any  ad- 
•ent  surface.  When  an  erysipelatous  infection  is  spreading  in 
ie  ~kin  it  often  terminates  abruptly  at  a  dense  portion  of  the  skin 
at  anatomic  lines,  along  which  the  >kin  i-  attached  tightly  to 


228  PRINCIPLES   OF   SURGERY 

underlying  structures.  Thus,  in  facial  erysipelas  the  tip  of  the  nose 
and  the  chin  usually  escape.  The  anatomically  related  lymph- 
nodes  become  more  or  less  enlarged. 

The  swelling  of  erysipelas  is  very  variable,  dependent  upon  the 
virulence  of  the  infection  and  particularly  upon  the  region  affected. 
The  looser  the  subcutaneous  tissue,  the  greater  the  swelling.  It 
is  at  times  so  great  that  the  entire  outline  of  the  part  is  destroyed. 

Burning  pain  is  complained  of,  and  the  inflamed  surface  is 
sensitive  to  pressure  or  manipulation,  but  in  the  milder  cases  only 
a  slight  discomfort  may  be  felt. 

When  a  wound  or  ulcer  that  has  been  suppurating  is  attacked 
by  erysipelas  the  discharge  is  reduced  or  ceases  entirely,  the 
surface  becomes  dry  and  of  a  glazed  appearance,  and  if  healthy 
granulations  were  present,  they  become  unhealthy  and  swollen. 
In  wounds  healing  by  first  intention  the  mechanical  bond  of  union 
is  interrupted  and  gaping  results.  At  the  beginning  of  involvement 
of  the  surrounding  skin  there  usually  appear  red  streaks,  leading 
away  from  the  margins. 

General  Symptoms. — The  period  of  incubation  is  short,  and 
ranges  from  fifteen  to  sixty-one  hours,  as  determined  by  Fehleisen 
in  fruitless  experiments  for  therapeutic  purposes. 

Following  a  period  of  incubation  of  fifteen  to  sixty-one  hours  the 
general  symptoms  of  erysipelas  are  ushered  in  with  a  chill;  there  is 
almost  no  exception  to  this  statement.  The  temperature  rises 
always  to  a  moderate  elevation,  but  frequently  to  a  very  high  de- 
gree. Usually  ranging  from  101°  to  103°  F.,  it  occasionally  reaches 
106°  F.  The  temperature  is  remittent  in  type,  and  the  normal  line 
may  be  reached  as  the  local  inflammation  subsides  at  the  expiration 
of  a  few  days,  but  this  is  no  assurance  that  it  will  not  rise  again. 
Recurrence  of  the  chill  usually  signifies  invasion  of  a  new  field,  and 
is  followed  by  another  rise  of  temperature ;  but  the  chill  may  re- 
cur even  daily,  without  evidence  of  extension.  These  variations 
may  recur  several  times  before  recovery.  The  pulse  runs  pan 
passu  with  the  temperature,  but,  in  asthenic  patients  and  those 
suffering  from  violent  infections,  becomes  rapid,  weak,  and  ir- 
regular, a  very  ill  omen.  Headache,  malaise,  anorexia,  and,  in  the 
severe  cases,  nausea  and  vomiting  are  present,  and  prostration  is 
out  of  proportion  to  the  local  inflammation.  Diarrhea  may  be 
present,  but  is  not  constant.  The  nervousness  and  restlessness  are 
at  times  so  marked  as  to  require  especial  consideration.  Delirium 
is  not  infrequent.  In  cases  terminating  fatally,  delirium  is  followed 
by  coma  and  death.  The  duration  of  an  attack  is  from  seven  to 
fourteen  days. 

The  chart  of  erysipelas  very  closely  resembles  that  of  lobar 
pneumonia.  The  initial  chill,  the  continuous  fever,  and  termina- 


ERYSIPELAS  229 

tion  by  crisis  shows  their  marked  similarity.  Either  of  them,  on 
the  other  hand,  may  terminate  by  lysis. 

The  leukocyte  count  is  variable  and  valueless.  Polymorpho- 
nuclears  are  usually  slightly  increased,  more  so  if  pus  is  present, 
and  eoMnophiles  are  reduced  at  the  height  of  the  disease. 

Types  of  Erysipelas. — The  following  terms  are  descriptive  of  the 
appearance  of  the  inflamed  part  and  of  the  exact  pathologic  stage 
reached.  They  are  not  exclusive,  for  any  of  them  may  be  converted 
into  any  subsequent  one  hi  a  few  hours.  They  are  erysipelas 
erythematosum,  erysipelas  vesiculosum,  erysipelas  pustulosum, 
am  1  erysipelas  phlegmonosum.  The  former  three  affect  only  super- 
ficial structures,  but  the  phlegmonous  type  affects  superficial  and 
deep  structures,  and  behaves  as  a  violent  cellulitis,  producing  nec"ro- 
sis  and  suppuration  of  the  deeper  tissues,  especially  the  deep  con- 
nect ive  tissue,  and  burrowing  extensively  among  the  anatomic  parts. 

Another  type  will  be  met  with  rarely,  viz.,  the  fulminating  or 
gangrenous;  gangrene  is  produced  by  the  dense  infiltration  (Kauf- 
maim),  aided,  of  course,  by  the  toxins. 

Wandering  Erysipelas  (Erysipelatis  Migrans  or  Ambulans). — 
Tliis  type  of  erysipelas,  by  its  wide  extension,  is  capable  of  con- 
tinuing longer  than  any  other.  It  gradually  extends  from  the  site 
of  primary  infection  and  along  the  surface  until,  spreading  by 
continuity,  it  has  progressed  from  one  hand  to  the  other,  or  from 
the  face  to  the  abdomen  or  thighs.  The  area  first  infected  is  usu- 
ally healed  long  before  the  limit  is  reached.  It  may  continue  for 
many  weeks,  but  is  usually  produced  by  a  mild  type  of  infection 
and  does  not  produce  severe  constitutional  symptoms. 

Metastatic  Erysipelas. — This  type  of  erysipelas  produces  second- 
ary areas  of  infection,  often  remote  from  the  primary  spot,  and  this 
without  direct  infection  through  a  new  atrium.  The  spread  is 
unquestionably  hematogenous,  and,  for  this  reason,  must  be  looked 
upon  as  being,  if  not  more  severe,  at  least  of  more  uncertain  prog- 
no-U.  The  only  case  of  metastatic  erysipelas  I  have  seen  was  an 
old,  feeble  patient .  v.  iio  died  four  days  subsequently  to  the  appear- 
ance of  the  secondary  patches. 

n>  current  Erysipelas. — This  term  is  applicable  to  those  cases 
which,  having  recovered  from  an  attack,  are  prone  to  develop 
suK-rquent  infections  from  the  same  source,  and  may  be  attributed 
to  infection  from  some  lesion  which  harbors  the  micro-organisms. 
Such  le-ions  are  fi>-mv-.  chronic  ulcers,  and  sinuses  or  fistula1. 
<>ne  of  the  most  frequent  sources  for  this  infection  is  necrotic  and 
carious  hone,  whose  sinuses  constantly  di-charue  their  contents  on 
tin-  -urface.  Kven  after  the  sinus  has  healed  temporarily  the  tir-t 
evidence  of  reopenint:  may  be  the  appearance  of  an  erysipelatous 
patch  around  it.-  mouth. 


230 


PRINCIPLES   OF   SURGERY 


Habitual  Erysipelas. — This  signifies  the  continued  presence  of 
infection  about  the  body  without  a  discoverable  lesion  and  a  well- 
marked  predisposition  toward  these  bacteria.  It  is  usually  facial, 
and  may  be  brought  on  by  the  slightest  provocation.  It  seems 
that  the  infection  awaits  constantly  the  least  abrasion  about  face, 
nose,  or  mouth,  and  will  not  fail  to  enter  the  least  scratch  or  abra- 
sion that  may  be  found.  It  is  more  frequent  in  alcoholics.  Such 
cases  are  not  especially  favorable  for  operative  work  in  the  field 
concerned. 

The  last  two  classes  illustrate  well  how  little  streptococci 
are  capable  of  minimizing  their  host  against  further  invasion. 

Facial  Erysipelas. — Erysipelas  of  the  head  usually  affects  the 
face.  The  scalp  and  nape  of  the  neck  are  frequently  attacked. 


Fig.  40. — Beginning  case  of  facial  erysipelas. 

The  atrium  of  infection  in  facial  erysipelas  is  frequently  situated 
within  the  nose,  mouth,  or  the  accessory  sinuses.  The  swelling  is 
often  intense,  owing  to  laxity  of  the  connective  tissue;  this  is 
especially  true  of  the  eyelids,  which  may  become  so  swollen  as  to 
close  the  palpebral  fissure,  not  only  so  that  voluntary  opening  of  the 
eyes  is  impossible,  but  even  passive  exposure  of  the  bulb  is  difficult. 
The  size  of  the  head  in  extensive  facial  erysipelas  is  markedly 
increased  and  the  individual  is  often  unrecognizable.  The  tip  of 
the  nose  and  the  chin  usually  escape  the  infection.  Erysipelas  of 


ERYSIPELAS 


231 


the  face  may  be  unilateral  or  bilateral.  Occasionally  the  mucous 
membrane  of  the  upper  air-passages  or  of  the  mouth,  pharynx,  or 
larynx  will  become  affected,  and  the  latter  are  always  of  the  gravest 
import,  for  the  intense  swelling,  when  it  reaches  the  fauces,  may 
extend  to  the  vocal  cords  and  result  in  asphyxiation  by  edema  of 
the  glottis,  or  produce  a  very  sinister  effect  on  deglutition  by  swell- 
ing of  the  pharyngeal  mucous  membrane. 

Tin-  constitutional  symptoms  are,  ccsteris  paribus,  more  intense 
in  facial  erysipelas  than  hi  that  of  other  regions,  and  the  mental 
symptoms  of  nervousness,  stupor,  delirium,  and  coma  are  found  in 


1  iu    1 1      S:mio  as  Fig.  40,  side  view,  showing  blebs  in  ear. 

a  higher  percentage  of  these  cases.     Cerebral  complications  are 
likewise  more  likely  to  develop  in  the  facial  type.. 

Erysipelas  Neonatorum. — In  the  newborn  the  infection  must 
gain  entrance  before  complete  cicatrization  of  the  navel,  which 
-erves  as  an  atrium.  Since  the  inauguration  of  antisepsis  and 
M-ep-i-  in  obstetric  practice  the  occurrence  of  this  fatal  type,  as 
well  as  of  the  remaining  types,  has  been  very  materially  reduced, 
and  many  physician-  of  extensive  experience  have  never  seen  a  case. 
Kry-ipela-  neonatorum  i-  frequently  coincident  with  puerperal 
>ep-i-  in  the  mother.  It  occasionally  a--ume-  a  phlegmonoUB  or 
form  in  the  advanced  stages.  Arteritis  and  phlebitis 


232  PRINCIPLES   OF   SURGERY 

are  frequently  associated,  and  extension  along  the  veins  may  lead 
to  infection  of  the  liver.  The  peritoneum  and  pleura  also  may  be- 
come inflamed.  Death  usually  occurs  at  the  expiration  of  a  week  or 
ten  days. 

Epidemic  Erysipelas. — No  recent  outbreaks  of  epidemic  ery- 
sipelas have  occurred.  The  last  epidemic  in  the  United  States 
was  in  1842  and  was  of  the  most  malignant  nature.  Owing  to  the 
frequent  involvement  of  the  tongue  the  disease  was  named  "  black 
tongue."  There  had  been  several  epidemics  in  the  various  coun- 
tries of  Europe  during  the  preceding  century.  Epidemic  erysipelas 
is  more  severe  than  sporadic  cases. 

Complications. — While  they  do  not  occur  with  great  frequency, 
there  are  several  possible  complications,  and  they  are  often  in- 
finitely more  serious  than  the  disease  itself. 

Septicemia. — Septicemia,  in  its  most  typic  and  virulent  form, 
may  arise  as  a  complication  of  even  a  mild  case  of  erysipelas, 
though  it  is  more  likely  to  come  in  the  severe  cases.  With  it  comes 
an  increase  in  the  severity  of  the  symptoms  and  the  hopelessness  of 
prognosis.  Streptococci  are  not  recoverable  from  blood  of  the  usual 
case  of  erysipelas,  but  in  septicemia  they  may  be;  but,  whether 
recoverable  or  not,  the  pathologic  findings  show  abundant  evidence 
that  hematogenous  distribution  of  the  bacteria  has  taken  place. 

Endocarditis  and  Nephritis. — Even  when  sufficient  numbers  of 
bacteria  have  not  entered  the  blood  to  establish  a  true  septicemia, 
enough  are  often  conveyed  thus  to  inaugurate  inflammatory  lesions 
of  the  heart,  of  which  endocarditis  heads  the  list  in  frequency. 
Again,  the  lodgment  of  bacteria  in  the  kidneys  during  the  efforts 
of  the  latter  to  eliminate  them  from  the  general  circulation  may 
result  in  a  more  or  less  intense  nephritis.  This  does  not  prove  that 
septicemia  has  complicated  the  case,  for,  as  has  been  shown 
elsewhere,  there  are  all  degrees  of  bacteremia  in  localized  infections, 
and  only  after  a  certain  dosage  has  been  reached  can  septicemia  be 
established.  This  complication  calls  for  most  attentive  supervision 
subsequent  to  recovery. 

Pneumonia. — Streptococcus  pneumonia,  possible  in  any  case 
of  erysipelas,  more  probable  when  a  large  hematic  infection  is 
present,  gives  evidence  of  pulmonary  involvement,  and,  while  the 
signs  may  be  confined  more  or  less  to  definite  areas,  one  is  more 
likely  to  find  both  lungs  universally  affected.  The  usually  typic 
picture  of  lobar  pneumonia  is  wanting,  and  the  general  and  local 
condition  is  more  like  catarrhal  pneumonia. 

Meningitis. — This  complication  is  occasionally  met  with  in 
infections  of  the  head,  face,  neck,  and  mucous  membrane  of  the 
mouth,  throat,  and  nose.  It  is  due  to  extension  along  the  lym- 
phatics or  veins  to  the  meninges. 


ERYSIPELAS  233 

Phlebitis  and  Thrombosis. — These  complications  may  occur  at 
any  point,  but  they  are  more  likely  in  erysipelas  of  the  lower  ex- 
tremities, due  probably  to  the  relatively  poor  circulation  of  the 
superficial  veins  of  these  parts.  Extension  through  the  emissary 
veins  to  the  cerebral  sinuses  may  occur  in  erysipelas  of  the  head 
:iml  face.  It  is  not  even  necessary  to  mention  the  gravity  of  such  a 
complication. 

Lymphangitis  and  Lymphadenitis. — The  unique  feature  of  ery- 
sipelas is  its  affection  of  the  superficial  lymph-spaces  and  vessels. 
It  is  only  a  step  further  to  inflammation  of  the  large  lymph-chan- 
nels. This  often  happens,  and  it  is  the  rule  to  find  enlargement  of 
the  lymph-nodes  receiving  drainage  through  the  affected  field. 
These  occasionally  suppurate  and  demand  treatment  accordingly. 
They  usually  subside  without  suppuration  when  the  local  condition 
i>  relieved. 

Sequelae. — Attention  is  directed  to  two  rare  sequelae  of  erysipe- 
las. The  first  is  elephantiasis.  This  condition  follows  only  after 
repeated  attacks.  It  is  seen  in  the  face,  giving  it  a  mask-like  ap- 
pearance, and  is  sometimes  seen  in  the  lower  thigh  in  cases  of  ulcer 
of  the  leg. 

The  second  sequela  is  blindness.  This  follows  facial  erysipelas 
and  is,  fortunately,  very  rare.  It  occurs  in  one  of  two  ways: 
fir-t.  by  "a  trophic  degeneration  of  the  optic  papilla,"  or,  second, 
'•1)\  panophthalmitis  with  suppuration  and  destruction  of  the  eye 
it>elf"  (Foster).  In  other  words,  it  is  a  phlegmonous  inflammation 
of  the  eyeball  and  possibly  of  the  other  orbital  contents. 

Diagnosis. — There  is  little  possibility  of  mistaking  erysipelas 
when  it  appears  with  its  typic  features.  The  redness,  induration, 
elevation,  abrupt  borders,  and  constitutional  symptoms  of  initial 
chill,  followed  by  fever,  make  a  picture  not  seen  in  other  diseases. 
The  chart  alone  would  lead  one  to  think  of  lobar  pneumonia,  but 
the  distinct  ion  is  cleared  by  physical  signs.  The  occurrence  of 
chill  and  fever  in  a  patient  who  has  had  a  recent  wound  should  lead 
to  a  thorough  investigation  at  once.  The  claim  is  made  that  a 
JMthognomonic  evidence  of  erysipelas  is  failure  of  the  temperature 
to  drop  on  the  morning  of  the  second  day  below  what  it  registered 
on  the  evening  of  the  first.  Ordinary  inflammatory  processes 
involving  the  skin  and  underlying  tissues  are  not  essentially  lymph- 
angitis. When  -uppuration  appears  it  is  probable  that  erysipelas 
i>  not  t  he  cause.  Erythemata,  both  septic  and  non-septic,  produce 
redne-s,  lnit  the  other  characteristic  signs  are  wanting.  The 
ephemeral  nature  of  many  erytheniata  is  important  negative  evi- 
dence. 

Prognosis. — The  outcome  of  erysipelas  i-  u-ually  favorable,  but 
where  it  occur*  in  the  very  young  or  the  very  old  and  feeble 


234  PRINCIPLES   OF   SURGERY 

it  is  much  more  grave.  There  is  a  special  danger  when  it  affects 
parturient  women,  as  sepsis  will  rarely  be  avoided.  Complications 
with  pneumonia,  septicemia,  and  thrombosis  of  cerebral  sinuses 
renders  the  prognosis  exceedingly  grave. 

Treatment. — The  treatment  of  erysipelas  is  prophylactic  and 
curative,  the  latter  being  subdivided  into  local  and  general. 

Prophylaxis. — Asepsis  is  the  habitual  means  used  to  prevent 
erysipelas,  but  imperfection  of  technic  renders  it  obligatory  to 
isolate  every  case  of  erysipelas  as  soon  as  the  condition  is  sus- 
pected, and  to  allow  no  one  to  come  in  contact  with  other  surgical 
or  obstetric  cases  while  attending  upon  erysipelas.  There  should 
not  only  be  isolation,  but  nothing  should  be  allowed  to  pass  from 
the  patient  to  the  kitchen  or  other  departments  of  the  hospital 
without  sterilization.  The  physician  who  is  compelled  to  dress  the 
case  should  be  excused  from  contact  with  any  patient  to  whom  the 
infection  may  be  transmitted.  It  is  better  that  all  dressings  be 
made  by  an  assistant  or  nurse,  or  that  the  case  be  turned  over  to 
some  young  physician  who  can  attend  it  without  great  danger. 
Obstetrics  and  surgery  must  not  be  done  by  the  attendant.  The 
nurse  and  attendant  should  take  care  that  no  wounds  are  present 
on  their  person  during  attendance.  If  the  physician  in  charge  is  so 
situated  that  he  cannot  escape  a  case  of  erysipelas,  and  must  con- 
tinue with  his  practice,  the  best  he  can  do  is  to  robe  himself  and 
wear  rubber  gloves  during  the  dressing,  and  it  would  be  better  for 
him  to  change  his  clothes  out  and  out.  After  recovery,  the  patient, 
all  attendants,  and  the  room  with  its  contents  must  be  sterilized 
and  all  clothing  changed;  in  all  cases  of  erysipelas  in  hospitals  no 
orderly  or  nurse  should  be  permitted  to  render  service  to  the 
patient  unless  they  can  be  made  clearly  and  intelligently  to  under- 
stand the  danger  and  the  restriction. 

Local  Treatment. — Numerous  remedies  and  procedures  have 
been  employed  locally  in  the  treatment  of  erysipelas,  most  of  them 
perhaps  of  mediocre  value  when  one  considers  that  the  disease 
itself  is  limited,  and  many  of  them  are  highly  praised  for  their 
signal  curative  properties.  There  is  no  specific  and  nothing  even 
approximating  it. 

It  is  best  in  cases  of  erysipelas  affecting  a  hairy  surface  to  cut 
the  hair  short.  Shaving  is  unnecessary.  The  longer  and  thicker 
the  hair,  the  more  necessary  it  is  to  cut  it,  for  it  serves  as  an 
obstacle  to  local  applications. 

Perhaps  the  most  satisfactory  local  application  is  ichthyol. 
It  is  used  in  the  form  of  an  ointment  with  vaselin  or,  preferably, 
lanolin  as  the  menstruum,  and  is  made  in  strengths  varying 
from  10  to  50  per  cent.  The  50  per  cent,  ichthyol  ointment  in 
lanolin  is  probably  the  best  treatment  so  far  discovered.  The  skin 


ERYSIPELAS  235 

should  be  washed  with  a  non-irritating  soap  and  warm  water  and 
dried  before  applying  the  ointment  on  gauze  mats.  The  ointment 
should  he  applied  at  least  twice  in  each  twenty-four  hours,  and 
should  n<>t  -imply  cover  the  inflamed  spot,  but  must  cover  a  sur- 
rounding margin  of  2  to  4  c.c.  It  is  superfluous  to  state  that  this 
treatment  i-  not  applicable  to  erysipelas  of  the  mouth  and  air- 
passages.  Bichlorid  of  mercury,  in  solution  1  :  1000,  is  perhaps  the 
mo-t  popular  treatment.  Compresses  saturated  in  this  solution 
are  applied  and  moistened  at  intervals  of  three  to  six  hours  as 
evaporation  takes  place.  Carbolic  acid,  in  1  to  5  per  cent,  solu- 
tion, i-  employed  in  the  same  way,  with  very  satisfactory  results, 
hut  the  increase  in  strength  by  evaporation  of  the  solution  on  the 
compresses,  and  the  tendency  to  produce  gangrene  when  applied 
continuou>l\ .  must  not  be  forgotten.  If  carbolic  acid  is  used  it 
i-  -at'er  to  change  compresses  each  time  rather  than  to  pour  the 
Dilution  on. 

Tincture  of  iodin  has  been  extolled  by  some;  the  writer  has 
had  no  experience  with  it.  Besides  being  an  antiseptic  it  has  the 
additional  advantage  of  counterirritation. 

I'.esides  local  surface  application,  carbolic  acid  or  bichlorid  of 
mercury  solutions  have  been  injected  into  the  skin  just  at  the 
periphery  of  the  inflamed  spot,  with  the  hope  of  checking  the  ad- 
vance of  the  infection.  Similarly,  the  surface  has  been  encircled 
at  the  margin  or  slightly  away  from  it  on  the  healthy  skin  with 
lunar  caustic;  encircling  compresses  have  been  applied  to  occlude 
the  lymphatic  spaces,  and  incision  through  the  skin  has  been  done 
to  interrupt  the  continuity  of  the  spaces  and  allow  granulations  to 
develop  before  the  infection  reaches  the  line  of  incision.  None  of 
these  treatments  are  widely  employed  and  they  cannot  be  recom- 
mended as  being  of  especial  service. 

The  constant  employment  of  a  saturated  solution  of  Epsom  salts 
in  water  has  been  experimented  with,  but  the  number  of  cases  is  too 
small  to  just  ify  an  opinion.  If  suppuration  or  gangrene  occurs  it  is 
subject  to  the  same  rule  here  as  under  ordinary  circumstances. 

Inasmuch  as  erysipelas  is  an  infective  inflammatory  process,  it 
is  very  justly  doubted  by  many  if  any  of  the  above-mentioned 
method-;  are  of  value,  and  certain  that  some  of  them  may  do  harm, 
either  from  toxicity  or  from  local  irritation  and  the  production  of 
er/.i ma,  as  happens  from  the  constant  employment  of  aqueous 
Dilutions.  Hence,  the  same  local  remedies  are  recommended  as  if 
the  part  were  infected  with  other  bacteria,  for  example,  staphylo- 
cocci  in  Mead  of  streptococci.  Rest,  elevation,  the  application  of 
soothing  lotion-  or  ointments  for  the  control  of  pain,  and  the  em- 
ployment of  Bier'-  hyperemia:  and,  when  the  swelling  is  intense  and 
imminent,  the  employment  of  incision  or  punctures;  cold 


236  PRINCIPLES   OF   SURGERY 

applications  should  not  be  made;  they  increase  the  danger  of 
necrosis.  No  question  can  be  raised  that,  with  our  present 
understanding  of  the  etiology,  pathology,  and  treatment  of  inflam- 
mation hi  general,  the  above  is  the  rational  course  to  pursue. 

Constitutional  Treatment. — Medicaments  taken  internally  are 
just  as  worthless  as  those  locally  applied  in  the  treatment  of  ery- 
sipelas, and  the  whole  internal  treatment  may  be  summed  up  in  the 
time-honored  statement,  "meet  the  indications."  The  important 
items  are  the  perfect  hygiene  of  the  room,  fresh  air  in  abundance, 
pure  water,  careful  nursing,  and  nutritious  and  stimulating  food. 
The  condition  of  the  heart  must  be  continuously  and  frequently 
observed,  and  signs  of  cardiac  weakness  or  of  reduced  blood- 
pressure  must  be  met  promptly.  Iron  in  large  doses,  frequently 
repeated,  has  long  had  great  reputation  in  the  treatment  of  this 
condition,  and  once  was  considered  almost  a  specific.  It  is  not;  so 
whatever  benefit  occurs  by  its  use  depends  upon  its  tonic  action. 
Elimination  of  the  poisons  by  natural  channels  is  the  greatest  hope 
for  benefit  in  internal  treatment,  and  water  in  abundance,  with  as 
much  assistance  as  the  moderate  use  of  laxatives  offers,  is  the  best 
remedy. 

Serum  Treatment. — This  has  proved  so  far  unsuccessful,  and, 
while  its  use  may  do  no  harm,  it  cannot  at  present  be  accepted  as 
influencing  the  prognosis  sufficiently  to  justify  its  administration. 
A  priori,  if  we  understand  that  erysipelas  may  be  produced  by  any 
one  of  a  vast  number  of  streptococci,  and  that  immunity  against 
one  obtains  for  that  one  and  no  other,  and  that  it  is  impossible  to 
recognize  the  strain  in  a  specific  instance,  it  is  easy  to  see  that, 
while  a  marvelous  cure  might  be  effected,  the  majority  would  not 
be  benefited. 

Curative  Action  of  Erysipelas. — The  occasional  recovery  of  a 
tedious  or  hopeless  pathologic  condition  led  the  profession  to  hope 
that  a  great  therapeutic  agent  was  to  be  found  in  erysipelas  in- 
fections. Gumma,  malignant  tumors,  especially  sarcomata,  and 
tuberculous  ulcers  have  been  known  to  heal  permanently  after 
being  infected  with  erysipelas.  Experiments  were  made  by  actu- 
ally inoculating  other  patients,  which  proved  more  difficult  than 
had  been  suspected.  Several  patients  died  of  erysipelas  and  few 
recovered  from  their  original  disease.  The  hope  was  not  sustained. 
Afterward  Coley's  fluid  was  used,  and  is  at  present  used  in  the 
treatment  of  inoperable  sarcomata.  A  very  small  percentage  of 
cures  have  followed  its  use,  and  no  deaths  from  the  fluid  have  been 
reported.  It  gives  the  benefit,  if  there  be  any,  without  the  danger 
of  a  vital  infection,  but  it  does  not  in  any  way  replace  the  need  for 
surgery  in  these  cases. 


CHAPTER  XI 
TETANUS,  LOCKJAW 

TETANUS  is  a  specific  disease  produced  by  the  bacillus  of  tet- 
anus of  Xicolaier,  and  is  characterized  by  tonic  spasms. 

Etiology. — The  bacillus  of  tetanus  is  a  spore-producing  anae- 
robe. The  spore  forms  in  the  end  of  the  bacillus  and  gives  it  the 
characteristic  drum-stick  appearance.  Great  numbers  of  the 
bacteria,  perhaps  the  majority  hi  a  given  field,  do  not  show  the 

nee  of  spores.  The  bacillus  is  a  native  of  the  soil,  and  is 
habitually  found  in  the  alimentary  tract  of  the  horse.  It,  there- 
f«  >rc.  appears  with  great  frequency  about  stables  and  hi  gardens  and 
fields  whore  stable  manure  is  used  as  a  fertilizer.  The  bacilli  also 
a  pi  war  in  great  numbers  hi  soil  where  refuse  from  the  kitchen  is 
thrown,  and  in  dust,  especially  street  dust.  In  the  tropics  the 
number  of  bacteria  seems  not  only  to  be  greater,  but  they  are  more 
virulent,  as  a  far  greater  percentage  of  the  total  mortality  is  due  to 
t  rt  anus  there  than  in  higher  latitutes,  while  a  smaller  percentage 
of  recoveries  occurs.  Tetanus  bacilli  are  occasionally  found  hi 
vaccine  virus,  and  several  cases  have  been  reported  from  the  use  of 
such  virus.  The  method  of  preparation  of  the  virus  makes  the 
demand  for  careful  technic  especially  necessary,  owing  to  the 
habitual  association  of  the  bacteria  with  dust,  manure,  and  hay 
which  has  been  cured  on  the  soil.  Furthermore,  several  cases  of 
postoperative  tetanus  have  been  traced  directly  to  an  infected 
catgut  which  had  not  been  freed  by  adequate  sterilization  from 
the  bacteria  it  held,  coming  as  it  does  from  the  alimentary  tract  of 
the  sheep  or  other  animals. 

The  fact  that  tetanus  bacilli  are  anaerobes  explains  the  relative 
infrequeney  of  the  disease,  as  it  is  incredible  that  no  more  wounds 
should  be  contaminated  from  this  source.  The  usual  type  of 
wound  causing  tetanus  is  the  punctured  wound,  less  frequently 
contused  wounds  and  abrasions.  Injury  to  the  tissues  and  the 
implantation  of  the  bacteria  into  the  tissues,  so  that  oxygen  cannot 
come  in  contact  with  them,  are  the  two  essentials.  General  resist- 
ance  of  the  patient  seems  to  play  an  important  part  in  the  etiology, 
a-  the  individual-  usually  affected  are  the  healthy,  robust  ones; 
they  who  are  most  liable  to  injury.  There  are  fewer  eases  in  the 
old  than  in  the  young,  apparently  for  the  same  reason.  Suppura- 
tive  wounds  seem  more  likely  to  cause  tetanus,  doubtless  because 

237 


238  PRINCIPLES   OF   SURGERY 

of  the  aerobic  bacteria  constituting  the  mixed  infection.  The 
destruction  of  oxygen  by  pyogenic  bacteria  renders  the  tissues  more 
anaerobic.  The  bacilli  are  said  to  be  more  virulent  in  mixed  infec- 
tion especially  with  saprophytes.  Similarly,  in  contused  wounds 
the  interference  with  normal  circulation  accomplishes  the  same  end. 
It  is  not  necessary  that  the  wound  should  be  large  or  deep;  the 
extent  of  the  injury  bears  no  relation  to  the  intensity  of  the  disease. 
Superficial  wounds  and  even  abrasions  and  scratches,  as  well  as 
hang-nails,  are  rarely  atria  for  infection;  these  atria  probably  admit 
the  germs  into  the  lymphatics,  and  their  lodgment  in  the  nodes 
affords  a  satisfactory  field  for  development.  Occasionally  tetanus 
develops  in  cases  of  simple  fracture  or  contusion,  explainable  only 
on  the  ground  of  hematogenous  infection.  The  so-called  idiopathic 
cases  are  due  to  small  wounds  which  have  escaped  observation  or 
been  forgotten,  or  to  wounds  of  the  alimentary  tract  infected  by 
ingested  bacteria.  The  presence  of  pyogenic  infection  or  even  of  an 
inflammation  of  the  wound  is  not  essential,  as  has  been  abundantly 
proved  by  the  development  of  tetanus  in  wounds  healing  per 
primam  before  the  onset  of  symptoms.  I  saw  a  fatal  case  of  tetanus 
recently  in  a  man  who  received  a  slight  abrasion,  T\  inch  in  diam- 
eter, while  repairing  a  trace  chain. 

The  wounds  from  which  tetanus  develops  are,  in  the  vast 
majority  of  cases,  wounds  of  the  extremities,  usually  the  hand  or  the 
foot  for  obvious  reasons.  They  are  more  frequently  wounded, 
and  more  frequently  come  in  contact  with  the  bacteria.  The 
feet  of  those  who  wear  worn-out  shoes  are  especially  susceptible. 
Bullet  wounds  are  especially  favorable  for  tetanus  infection,  and, 
if  history  can  be  trusted,  are  more  likely  to  become  infected  when 
wounded  soldiers  are  compelled  to  lie  for  hours  on  the  ground  after 
a  rain. 

The  most  common  agent  inflicting  tetanus  wounds  is  the  rusty 
nail,  of  which  the  laity  are  so  much  afraid.  The  fact  that  the  nail  is 
rusty  is  immaterial,  but  that  it  should,  after  rusting  or  while  rust- 
ing, become  contaminated  with  tetanus  bacilli,  and,  when  con- 
taminated, is  sure  to  deposit  them  within  the  tissues,  is  the  essen- 
tial feature.  Rust  is  unnecessary  to  this  end.  The  effect  of 
injecting  contaminated  earth  into  wounds  has  long  been  known 
even  to  barbarians,  some  of  whom  poisoned  their  arrows  in  this 
way.  Wounds  inflicted  by  explosives  or  toy  pistols  and  similar 
playthings  are  especially  likely  to  produce  tetanus,  as  the  Fourth  of 
July  sacrifices  in  the  United  States  have  long  attested.  They 
produce  the  right  kind  of  wounds  and  carry  their  own  tetanus 
bacilli,  contained  in  the  earth  used  in  their  manufacture. 

Pathology. — The  bacteria  of  tetanus  are  found  in  small  num- 
bers in  the  region  of  the  wound,  and  until  recently  were  thought  to 


TETANUS,    LOCKJAW 


2:v.» 


be  confined  to  this  limit.  Recent  investigations,  however,  have 
shown  that  they  are,  at  times  at  least,  recoverable  from  the  inguinal 
lymph-nodes  in  infections  of  the  foot,  a  very  important  discovery 
from  the  standpoint  of  treatment.  They  have  also  been  recovered 
from  the  blood  and  the  viscera. 

Tin-re  is  no  characteristic  pathologic  change  in  tetanus.     Some 
ibe  inflammatory  changes  in  the  central,  and  occasionally  in 


' 


I  in.  U.     ( '.isc  df  Manns  recovering.     Note  the  extent  to  which  mouth  can  be 
opened,  and  the  wounded  finger  which  served  as  an  atrium. 

the  peripheral,  nerve  structures,  while  others  report  their  inability 
to  find  them.  The  real  change  explanatory  of  the  symptoms  is  a 
chemie  c(iml. ination  between  the  toxin  totanospasmin  and  the 
nerve-centers:  the  uross  changes  are  probably  only  incidental. 
Be-ide<  tetanospasmin  the  bacillus  produces  also  tetanoly>in. 

Symptoms.  -The  period  of  incubation  of  tetanu*  varie<  widely, 
from  one  day  to  several  week-.     The  majority  of  cases  develop 


240  PRINCIPLES   OF   SURGERY 

within  two  weeks,  and  almost  all  the  remainder  either  in  the  third 
or  the  fourth  week.  Occasionally  longer  periods  are  reported,  the 
extreme  time  mentioned  being  eight  and  one-half  weeks. 

The  beginning  symptoms  of  tetanus  are  usually  ascribed  by  the 
patient  to  a  contraction  of  cold,  which  is  felt  as  a  soreness  hi  the 
neck,  or  a  stiffness  in  the  muscles  of  this  region.  Further  than 
this  there  is  no  discomfort.  Then  the  muscles  of  mastication  are  in- 
volved, and,  besides  being  sore,  they  contract  so  that  the  mouth 
can  either  not  be  opened  or  only  partially  opened.  This  symptom 
is  called  trismus.  Then  the  voluntary  muscles  of  the  body  become 
involved,  and  no  group  may  escape,  although  the  upper  extremities 
are  affected  less  than  the  remaining  muscles  and  may  escape  al- 
together. I  have  not  seen  them  free  from  contraction  in  any  per- 
sonally observed  case.  Involuntary  muscles  are  unaffected. 

The  spasms  are  tonic,  and  while  clonic  spasms  may  occur  when 
the  muscles  are  first  affected,  they  soon  become  tonic.  They  come 
on  at  the  slightest  disturbance  of  the  sensorium,  remain  for  a  few 
seconds  to  a  minute  or  more,  and  disappear.  But  the  tone  of  the 
voluntary  muscles  is  always  exaggerated  hi  tetanus,  so  that  even 
between  spasms  there  is  an  unnatural  stiffness  of  the  body.  The 
slightest  noise,  touch,  or  light  may  call  forth  a  spasm.  The  con- 
traction may  be  slight  hi  the  milder  cases,  but  hi  the  severer  ones 
the  tension  limit  of  the  muscles  is  reached.  Tendons  are  occa- 
sionally ruptured  or  pulled  loose  at  their  insertions  and  sometimes 
fracture  is  produced.  The  spasms  produce  soreness  of  the  muscles. 
The  peculiar  expression  of  the  countenance,  known  as  risus  sar- 
donicus,  or  the  sardonic  grin,  is  produced  by  contraction  of  the 
facial  muscles.  It  is  more  or  less  marked  between  the  spasms, 
and  intense  and  hideous  during  their  presence.  It  is  sometimes 
absent.  The  peculiar  expression  of  the  countenance,  that  of  one 
straining  every  fiber  of  his  being  to  lift  an  immovable  burden,  the 
clenched  jaw,  the  dilated  nostrils,  the  passage  of  the  breath  and 
froth  through  the  occluded  teeth,  the  eyes  retracted  into  the 
sockets,  and  the  countenance  beaded  or  bathed  with  perspiration 
and  of  a  cyanotic  hue,  the  wrinkled  skin  of  brow  and  cheek  (tetano- 
facies),  is  a  picture  that  no  eye  which  has  seen  it  could  fail  to  recog- 
nize again.  Not  only  so,  the  moaning  of  these  patients  during  the 
spasms  adds  to  the  pity  their  appearance  calls  forth.  The  spasms 
affect  the  diaphragm,  and,  if  the  contraction  of  this  muscle  is 
intense,  a  pain  along  the  origin  of  the  muscle  is  complained  of— 
it  is  the  girdle  pain. 

Owing  to  greater  violence  hi  the  contractions  of  various  groups 
of  muscles,  the  body  assumes  certain  attitudes.  The  most  com- 
mon of  these  is  opisthotonos,  in  which  the  body  is  arched  with  the 
concavity  backward,  so  that  if  the  patient  lies  upon  his  back  only 


TETANUS,    LOCKJAW  241 

the  occiput  and  the  heels  rest  upon  the  bed.  Emprosthotonos  is 
the  attitude  of  bending  the  body  forward,  due  to  excessive  contrac- 
t  it  ins  of  the  recti  abdominis.  Pleurothotonos  is  bending  of  the 
body  to  either  side;  it  is  rare.  Orthotonos  is  fixed  rigidity  of  the 
body  in  the  straight  position. 

The  tetanus  patient  lies  as  quietly  as  possible,  afraid  to  move, 
afraid  to  eat  or  drink,  afraid  to  attempt  relief  of  his  bowels  or 
Madder,  for  not  only  are  these  functions  impossible  or  at  least 
only  ixx>r,  their  performance,  even  each  attempt  at  their  perform- 
ain •' •.  brings  about  a  new  general  spasm.  Hence,  feeding  the 
patient  and  quenching  his  thirst  may  become  difficult  problems, 
while  relieving  the  bladder  and  rectum  becomes  at  times  well  nigh 
imi>ossible. 

The  temperature  is  an  interesting  item;  it  is  slightly  to  moder- 
ately elevated,  from  100°  to  103°  F.,  and,  so  far  as  treatment  is 
corcerned,  is  negligible.  Toward  the  end  of  life  the  temperature 
rises  very  high,  from  108°  to  112°  F.,  and  may  continue  to  rise  for  a 
time  after  death,  although  there  is  usually  a  drop  just  before  death. 
The  pulse,  at  first  but  slightly  accelerated,  becomes  more  rapid 
during  the  spasms,  and,  as  the  exhaustion  increases,  very  rapid  and 
weak.  In  cases  whose  circulatory  apparatus  is  weak  death  may 
be  attributable  directly  to  accidents  from  this  source.  Rupture 
of  a  fatty  heart  has,  for  instance,  been  observed. 

During  all  the  painful  spasms  the  unfortunate  victim  is  doomed 
to  remain  conscious,  and,  while  still  exhausted  from  the  last  spasm, 
to  dread  the  advent  of  another.  They  remain  conscious  usually  to 
the  end. 

The  termination  of  the  hideous  scene  is  a  welcome  to  the 
sufferer  and  to  his  friends.  Death  is  brought  about  by  suffocation 
during  a  violent  spasm  of  the  muscles  of  respiration,  by  accidents 
to  the  circulatory  apparatus,  by  sheer  exhaustion,  by  paralysis  of 
the  heart,  by  aspiration-pneumonia,  and  by  spasm  of  the  glottis. 

Types. — Traumatic  tetanus  is  a  term  applicable  to  almost 
every  case  of  tetanus  seen  in  which  wound  infection  has  been  pro- 
duced. 

The  term  idiopathic  tetanus  has  been  practically  discarded.  It 
was  formerly  applied  to  those  unexplainable  cases  of  tetanus  where 
no  atrium  could  be  discovered. 

Acute  Tetanus. — In  this  type,  to  which  the  vast  majority  of 
belong,  the  period  of  incubation  is  less  than  fourteen  days, 
and  the  duration  of  the  disease  is  from  one  day  to  two  weeks,  usually 
terminating  fatally.  The  symptoms  are  more  violent,  the  course 
shorter,  and  the  outcome  much  worse  than  in  chronic  tetanus. 
Rarely  acute  tetanus  becomes  chronic. 

Chronic  tetanus  may  follow  acute  tetanus,  or  the  disease  may 

16 


242  PRINCIPLES   OF   SURGERY 

assume  the  chronic  type  from  the  beginning.  The  symptoms 
are  less  intense  and  more  prolonged,  the  period  of  incubation  is 
more  than  two  weeks  usually,  and  the  prognosis  is  far  more  favor- 
able. It  may  last  for  weeks  or  months,  and  the  contraction  of  the 
facial  muscles  may  persist  indefinitely  in  some  degree  after  recovery. 

Tetanus  Hydrophobicus,  Facial  or  Head  Tetanus. — This  pecu- 
liar type  of  tetanus  follows  infection  hi  the  distribution  of  the  cra- 
nial nerves.  It  is  afebrile.  The  onset  is  frequently  preceded  by 
paralysis  of  a  cranial  motor  nerve,  usually  the  seventh,  but  never 
the  motor  branch  of  the  third  division  of  the  fifth.  The  paralysis 
always  occurs  on  the  side  of  the  injury,  and  may  antedate  the  onset 
of  spasms  several  days.  In  the  milder  form  the  spasms  affect 
only  the  distribution  of  the  cranial  nerves,  particularly  the  muscles 
of  mastication  (trismus)  and  those  of  the  larynx  and  pharynx, 
whence  the  name  tetanus  hydrophobicus.  But  in  the  more  severe 
forms  the  disease  may  extend  to  the  whole  body,  as  hi  ordinary 
acute  tetanus.  Tetanus  hydrophobicus  is,  as  a  rule,  less  severe, 
and  offers  a  better  prognosis  than  acute  types. 

Trismus  Nascentium,  Tetanus  of  the  Newborn. — The  atrium  is 
the  umbilicus  or  the  cord.  The  disease  is  rare  in  modern  obstet- 
ric practice.  The  period  of  incubation  is  from  one  to  five  days,  and 
is  hi  no  important  detail  different  from  ordinary  acute  tetanus. 
The  efforts  of  the  child  to  nurse  are  eager,  but  the  nipple  is  soon 
turned  loose,  for  the  attempt  to  swallow  brings  on  the  spasm. 
This  type  of  tetanus  is  fatal,  and  the  average  duration  of  life  is  a 
little  shorter  perhaps  than  in  ordinary  acute  tetanus. 

Puerperal  Tetanus. — This  form  of  tetanus  is  likewise  extremely 
rare;  it  is  found  more  frequently  in  communities  where  obstetric 
practice  is  done  by  ignorant  midwives,  and  in  cases  of  criminal 
abortion,  produced  frequently  by  women  inserting  dirty  instru- 
ments into  their  own  uteri.  In  cases  where  laceration  of  the  cervix 
uteri  or  the  perineum  occur,  and  where  severe  traumatism  is  done 
to  the  mucous  and  submucous  tissues,  these  injured  parts,  as  well 
as  the  endometrium,  may  serve  as  portals  of  entry  for  the  infection. 

Local  Tetanus. — A  few  cases  are  reported  in  which  tetanic 
spasms  affect  only  the  group  of  muscles  supplied  by  the  nerve  which 
has  conveyed  the  toxins  to  the  cord  centers.  It  is  a  mild  form  of 
tetanus,  and  has  a  favorable  prognosis.  It  is  very  likely  to  be 
overlooked. 

Diagnosis. — Tetanus  may  be  confused  with  tetany,  strychnin- 
poisoning,  hysteria,  hydrophobia,  meningitis,  but  a  consideration 
of  the  history  and  the  mode  of  onset  will  usually  make  it  possible 
to  differentiate  tetanus  from  all  other  conditions.  The  finding  of 
tetanus  bacilli  in  the  discharges  from  the  wound  is  absolute  proof 
of  the  nature  of  the  disease. 


TETANUS,    LOCKJAW  243 

Tetany  is  associated  with  disease  or  excision  of  the  para- 
thyroid glands,  with  dilation  of  the  stomach,  and  gastro-intestinal 
•  li-t  urbances.  It  is  seen  more  frequently  in  the  young,  if  cases  due 
to  excision  of  the  parathyroids  are  excluded.  It  is  not  associated 
with  a  wound.  It  affects  the  muscles  of  the  upper  extremities 
more  frequently  and  more  extensively  than  the  remaining  muscles. 
The  spasms  are  intermittent.  It  is  more  frequent  in  certain  parts 
of  the  world.  Four  important  signs  serve  to  distinguish  it  from 
tetanus,  any  one  of  which  may  be  wanting  in  a  given  case.  The 
first  of  these  is  the  position  of  the  hand  during  the  spasms;  it  is 
known  as  the  obstetric  (accoucheur's)  hand,  and  is  suggestive  of 
the  hand  ready  to  make  a  vaginal  examination.  Second,  is 
( 'hvostek's  sign,  which  shows  increased  excitability  of  the  motor 
nerves  to  mechanic  stimulation;  for  example,  tapping  gently  over 
the  pes  anserina  produces  spasms  of  the  muscles  supplied  by  the 
facial  nerve.  Third,  Erb's  sign  is  the  increased  electric  excitability, 
especially  to  the  galvanic  current.  This  is  true  for  both  motor  and 
sensory  nerves;  muscular  response  can  be  produced  by  the  employ- 
ment of  currents  varying  from  0.5  to  2  ma.,  which,  under  normal 
circumstances,  fails  to  stimulate  contractions.  Fourth,  Trous- 
seau's sign.  This  consists  hi  making  pressure  over  the  nerves  or 
blood-vessels  supplying  an  extremity  during  the  interval  between 
spasms,  and  thereby  evoking  an  attack.  During  the  spasms  their 
number  is  increased  by  the  same  maneuver. 

Strychnin-poisoning  is  distinguished  by  the  history  of  taking 
poison,  by  recovering  it  from  the  stomach  contents,  by  the  ab- 
sence of  a  gradual,  slow,  definite  method  of  onset,  by  the  green 
border  to  objects  of  vision,  by  the  rapidity  of  progress,  and  by  the 
appearance  of  violent  convulsions  from  the  beginning;  the  absence 
of  a  wound,  or,  if  one  is  present,  failure  to  find  tetanus  bacilli. 
Kvidence  of  gastric  irritation  is  present  in  strychnin-poisoning.  In 
Strychnin-poisoning  there  are  intervals  of  complete  relaxation;  they 
ure  absent  in  tetanus.  Trismus  is  late  in  strychnin-poisoning  and 
the  eye-  protrude  during  the  spasm. 

Ihixtirin  usually  gives  a  history  of  such  attacks,  and  bears 
eviolence  of  nervous  phenomena  not  found  in  tetanus.  The 
ab-ence  of  trismus  in  the  usual  hysteric  ditTerentiates  the  two  - 
if  trismus  i-  present,  recurrence  of  the  spasm  is  not  rhythmic;  the 
-pa-ins  are  not  induced  in  hysteria,  as  in  tetanus,  by  slight  sensory 
disturbances.  The  amenability  of  many  hysterics  to  suggestion 
is  characteri-tic.  The  spasms  of  hysteria  may  be  prolonged  much 
longer  than  those  of  tetanus,  ami  relaxation  in  the  intervals  is 
complete.  The  absence  of  t  he  -anlonic  ijriii  and  of  untold  suffering 
i-  -imiificant :  in  hysteria  the  consciousness  of  the  approaching 
.-pa-m  ami  the  dread  of  the  pain  from  it  are  not  present  as  in 


244  PRINCIPLES   OF   SURGERY 

tetanus.  There  is  invariably  a  betraying  feature  of  the  hysteric, 
which  a  little  attention  and  tact  can  detect,  however  closely  it  may 
simulate  tetanus. 

Hydrophobia. — The  period  of  incubation  of  tetanus  is  mujch 
shorter  than  that  of  hydrophobia,  and  this  alone  will,  in  the  major- 
ity of  cases,  even  in  those  where  tetanus  results  from  a  bite,  dis- 
tinguish the  two.  Trismus  does  not  occur  in  hydrophobia;  opis- 
thotonos  rarely.  The  mental  symptoms  are  marked  in  this  disease 
— restlessness,  uneasiness,  change  of  disposition,  and  delusions  are 
common.  The  spasms  usually  begin  in  the  larynx  and  pharynx. 
The  spasms  may  be  similar  to  those  of  tetanus — i.  e.,  tonic — but 
are  usually  clonic. 

Cerebrospinal  Meningitis. — This  disease  shows  no  trismus,  but 
the  rigidity  begins  in  the  neck.  Headache,  the  history,  the  ap- 
pearance of  delirium  or  coma,  the  changes  in  the  fundus  of  the 
eyes,  Kernig's  sign,  and  gastric  disturbances  indicate  meningitis. 
The  withdrawal  of  fluid  by  lumbar  puncture  and  discovery  of  the 
causative  bacteria  therein  and  improvement  in  symptoms  after 
the  puncture  are  pathognomonic. 

Complications  and  Sequelae. — Patients  who  have  tetanus  rarely 
show  complications,  inasmuch  as  the  bacteria  do  not  affect  the 
tissues  directly  or  locally,  but  by  the  action  of  the  toxins  on  the 
nerve-centers.  Accidents  may  occur  as  a  result  of  the  severe 
spasms,  such  as  fracture  or  rupture  of  various  soft  structures. 
The  most  frequent  sequel  is  stiffness  and  soreness  of  the  muscles. 
This  may  last  for  several  months.  Rarely  risus  sardonicus  seems 
persistent  after  recovery.  Paralysis  and  mental  disturbance  may 
follow  recovery,  but  they  are  infrequent. 

Prognosis. — The  chances  of  recovery  from  tetanus  are  very 
poor.  The  longer  the  period  of  incubation  beyond  ten  days,  the 
better  is  the  chance  of  recovery;  also,  the  longer  the  disease  contin- 
ues beyond  ten  days  the  better  the  chance  of  recovery,  and  if  it 
reaches  the  fifteenth  day  each  subsequent  day  adds  greatly  to  the 
chances  of  recovery.  Chronic  tetanus  offers  a  much  better  prog- 
nosis than  acute.  Acute  tetanus  (developing  within  ten  days  of  the 
injury)  has  a  mortality  of  approximately  80  per  cent.,  but  in  chronic 
cases  which  have  continued  longer  than  fifteen  days  the  mortality 
is  something  less  than  10  per  cent.  "The  mortality  is  much  less  in 
cases  which  have  had  the  disease  fifteen  days  or  more  than  in  those 
whose  period  of  incubation  has  run  the  same  time,  8  per  cent, 
against  40  per  cent.  About  1  case  in  every  4  or  5  is  chronic  (211 
out  of  870)  (Anders). 

Treatment. — Treatment  of  tetanus  is  preventive  or  prophy- 
lactic and  treatment  of  the  attack.  The  former  is  very  efficient, 
the  latter  very  discouraging.  Therefore  it  is  necessary  for  the 


TETANUS,    LOCKJAW  245 

physician  to  determine  whether  the  nature  of  a  wound  and  the 
circumstances  under  which  it  was  produced  demand  prophylactic 
treatment.  Wounds  soiled  with  earth  or  dust,  those  produced  by 
objects  which  have  been  associated  with  stables  or  horses,  or  which 
have  been  hi  contact  with  the  soil,  those  made  on  parts  of  the  body 
that  have  possibly  been  soiled  by  tetanus  bacilli,  and  those  pro- 
duced by  toy  explosives,  all  come  under  the  suspicious  group. 
More  particularly,  punctured  wounds  and  contused  wounds  must 
be  held  in  suspicion.  Wounds  made  by  rusty  nails  and  tacks 
which  have  been  lying  on  the  ground  or  about  the  barnyard  and 
Han  Ion  are  especially  dangerous,  but  any  punctured  wound  may 
carry  infection  from  the  shoe  or  the  surface  of  the  foot. 

Preventive  Treatment. — All  suspicious  wounds  should  be 
treated  at  the  first  dressing,  so  as,  if  possible,  to  avoid  the  devel- 
opment of  tetanus.  A  great  percentage  of  the  cases  of  tetanus 
seen  in  private  practice  come  from  wounds  which  have  received 
no  medical  attention.  Hence,  the  physician  should  teach  his 
clientele  the  importance  of  first-aid  services  in  all  wounds.  If 
the  wound  is  punctured,  it  should,  under  aseptic  conditions,  be 
converted  into  an  incised  wound  and  kept  open  by  packing.  All 
foreign  material  must  be  removed.  In  certain  instances  it  is 
better  to  excise  the  whole  wound  and  a  sufficient  width  of  adjacent 
tissue  to  make  sure  the  infection  is  removed.  The  surface  of  the 
wound  should  be  cleansed  of  all  blood-clots  and,  particularly,  of  all 
devitalized  tissue.  Cleanse  further  by  applying  peroxid  of  hy- 
drogen. This  should  be  repeated  at  intervals,  and  the  gauze  pack- 
ing should  by  preference  be  saturated  with  it.  Apply  an  antiseptic 
solution  continuously  for  fifteen  to  thirty  minutes.  Tincture  of 
iodin  applied  to  the  wound  surface  is  the  most  certain  antiseptic. 
Five  per  cent,  solutions  of  carbolic  acid  or  lysol  are  perhaps  the 
most  widely  employed  agents,  and  the  solution  should  be  allowed 
to  run  into  the  wound  and  should  come  in  contact  with  every 
crevice  and  corner.  Afterward  thoroughly  dry  the  wound. 
The  wound  should  never  be  cauterized  either  with  actual  or  poten- 
tial cauterants,  as  this  may  fail  to  reach  all  the  bacilli,  and  renders 
the  field  unmistakably  more  suitable  to  the  development  of  anae- 
robes. If  pyogenic  infection  occurs,  the  pus  should  not  be  allowed 
to  accumulate  in  the  wound.  In  any  instance,  dressings  should  be 
made  two  or  three  times  daily  and  fresh  gauze  introduced,  either 
dry  or  saturated  with  iodin,  or  a  solution  of  lysol,  carbolic  acid,  or 
peroxid.  Medicated  gauze  is  worse  than  useless.  The  best 
d rosing  to  apply  is  the  powdered  dry  antitetanic  serum.  If  this 
i^  u-ed  the  dressings  need  not  be  repeated  oftener  than  daily  or  on 
alternate  days. 

Prophylactic  doses  of  antitetanic  serum  should  be  adminis- 


246  PRINCIPLES   OF   SURGERY 

tered  in  absolutely  every  case,  even  if  only  slightly  suspicious. 
In  those  cases  where  the  bacilli  can  be  demonstrated  in  the  wound 
it  is  imperative.  Fifteen  hundred  units  of  serum  is  supposed  to  be 
a  preventive  dose.  Or,  if  not  given  in  units,  20  c.c.  or  more  may 
be  given.  The  serum  causes  no  evil  results,  save  occasionally  a 
cutaneous  rash  and  soreness  at  the  point  of  injection.  Prophylactic 
doses  are  given  usually  beneath  the  skin.  In  very  suspicious  cases 
it  is  wise  and  safe  to  repeat  the  dose  each  day  for  two  or  three  days. 

Treatment  of  the  Attack. — After  tetanus  has  developed,  the 
treatment  is  very  unsatisfactory ;  and  it  is  questionable  if  treatment 
has  so  far  changed  the  mortality  materially,  although  encouraging 
results  are  occasionally  reported  from  various  plans  of  treatment; 
but  the  number  of  cases  is  too  meager  to  admit  of  even  remotely 
accurate  conclusions.  All  patients  who  have  received  suspicious 
wounds  should  be  instructed  to  keep  in  close  touch  with  their 
physicians  for  at  least  two  weeks,  for  the  above  treatment  is  not  an 
infallible  preventive  of  tetanus. 

The  question  arises  whether  it  is  safe  to  admit  a  patient  who 
has  tetanus  into  a  hospital.  If  there  is  an  open  wound,  admittedly 
it  is  not  safe.  If  there  is  no  open  wound,  it  is  comparatively  safe, 
although  tetanus  bacilli  have  been  recovered  from  the  feces  of 
patients  having  the  disease.  This,  however,  may  be  accidental, 
as  they  probably  are  frequently  admitted  into  the  alimentary  tract 
of  healthy  people. 

After  the  tetanus  toxins  have  combined  with  the  central  nervous 
tissues  it  seems  impossible  to  free  them;  whether  this  is  due  to  the 
fixity  of  the  combination,  or  to  the  inaccessibility  of  these  tissues  to 
the  antitoxin  circulating  hi  the  blood,  is  not  known.  However, 
it  is  necessary  to  neutralize  the  uncombined  toxins  by  the  admin- 
istration of  antitoxin.  This  has,  for  manifest  reasons,  proved  to 
be  more  efficient  when  practised  in  the  beginning  of  the  disease, 
during  the  first  thirty  hours.  Antitoxin  has  been  administered 
in  the  following  ways:  it  may  be  injected  into  the  subcutaneous 
tissues,  as  mentioned  above;  it  may  be  administered  intravenously; 
it  may  be  given  by  injection  directly  into  the  nerve  sheath,  with  the 
hope  of  interrupting  further  transmission  of  the  toxin  along  the 
trunk;  it  is  injected  into  the  dura  mater  of  the  cord,  just  as  hi  spinal 
analgesia;  or  it  is  deposited  directly  into  the  lateral  ventricle  of  the 
brain  by  trephining  a  very  small  opening  into  the  skull,  1  to  lj 
inches  lateral  to  the  bregma,  inserting  a  needle  vertically  into  the 
brain  until  cerebrospinal  fluid  escapes,  which  shows  that  the  ven- 
tricle has  been  entered  (Kocher).  The  dosage  of  the  serum  in 
tetanus  is  undetermined,  but  it  seems  necessary  to  administer 
large  daily  doses,  or  perhaps  several  smaller  doses,  and  to  continue 
its  use  until  free  from  danger.  The  acute  cases  of  tetanus  seem 


TETANUS,    LOCKJAW  247 

not  to  be  influenced  by  serum,  and,  as  the  chronic  CMOfl  offer  a 
better  prognosis  naturally,  it  has  not  been  decided  how  much  they 
may  be  helped  by  it. 

If  the  wound  has  not  received  proper  treatment  from  the 
I  •rm  nning,  or  if  it  has  been  closed,  the  first  step  should  be  to  open 
it  or  dissect  it  out,  and  treat  according  to  the  rules  laid  down  under 
preventive  treatment.  Since  demonstration  of  tetanus  bacillus 
in  the  lymph-nodes  has  been  made,  it  theoretically  reduces  the  old 
method  of  treatment  by  amputation  after  the  development  of 
symptoms  to  the  same  value  its  practical  results  have  shown. 

It  is  necessary  to  place  the  patient  under  such  surroundings 
as  will  least  tend  to  excite  spasms,  for,  while  this  cannot  thwart 
them,  it  adds  a  little  to  the  physical  comfort.  Especial  atten- 
tion should  be  given  to  the  bladder  and  bowels,  and  they  should  be 
attended  to  regularly  by  a  competent  nurse.  Although  assistance 
along  these  lines  will  excite  spasms,  they  will  be  far  less  frequent 
than  the  continual  unsatisfied  efforts  of  the  patient  would  produce. 
Nourishment  and  drink  must  be  given  if  possible,  but  if  swallowing 
is  impossible  these  should  be  given  at  regular  intervals  through  a 
>m:ill  stomach-tube. 

Control  of  the  spasms  of  tetanus  offers  great  difficulties,  and 
every  known  narcotic  and  sedative  has  been  tried.  The  number 
id  v ing  the  best  results,  usually  poor  at  that,  is  small.  It  is  probable 
that  the  drugs  recommended  as  giving  the  highest  percentage  of 
< Miies  have  depended  for  their  effect  solely  on  their  potency  for 
<•<  >nt  rol  of  spasm.  At  the  head  of  the  list  stands  chloroform,  which, 
administered  by  inhalation,  gives  very  satisfactory  temporary 
control.  Anesthesia  is  unnecessary,  and  the  drug  should  be  pushed 
only  to  the  point  of  control.  The  chief  objection  to  it  is  that  it 
cannot  be  continued  indefinitely,  and  the  spasms  recur  shortly 
after  its  discontinuance.  Opium  (usually  morphin  given  hypo- 
dermically)  is  very  satisfactory,  but  must  be  given  in  heroic  doses 
to  relax  the  spasm.  There  are  two  objections  to  its  use:  first,  the 
inhibitory  action  on  respiration,  and,  second,  the  interference  with 
elimination.  Physostigmin  is  lauded  by  many  as  a  most  effective 
anti-pasmodic  in  tetanic,  but,  like  all  narcotics,  must  be  given  in 
enormous  doses.  Chloral  hydrate  in  maximum  dosage  gives  per- 
\\;i\><  as  good  results  as  any  drug;  the  daily  amount  needed  to  pro- 
duce ,-leep  in  severe  cases  runs  as  high  as  3  drams  or  more.  It 
i,-  more  efiirient  when  combined  with  morphin,  and  its  depressant 
action  on  the  heart  must  be  counteracted  by  appropriate  stimula- 
tion. Carbolic  acid  injected  along  the  spine  has  been  used,  but 
only  in  a  limited  way.  The  employment  of  carbolic  acid,  injected 
hypodermically  or  intravenously  in  1  to  :}  per  cent,  aqueous  solu- 
tion-. ha>  -ho\vn.  in  the  cases  reported  by  Baccelli,  higher  percent- 


248  PRINCIPLES   OF   SURGERY 

ages  of  cures  than  any  other  treatment.  Tetanus  patients  have 
great  tolerance  for  this  drug,  and  it  is  thought  that  many  failures 
reported  were  due  to  insufficient  quantities.  The  daily  dose  should 
run  from  \  to  \\  gm.  or  higher,  if  the  urine  shows  no  evidence 
of  poisoning.  In  moderately  severe  cases  the  mortality  has  been 
2  per  cent.,  and  hi  very  severe  cases  it  has  been  as  high  as  18  per 
cent.  The  injections  are  repeated  every  two  hours,  and  each  dose 
is  from  1  to  2  drams  of  a  \  of  1  per  cent,  solution.  Willard  H. 
Hutchings  has  reported  a  series  of  6  cases  of  tetanus  in  which  chlore- 
tone  was  employed  to  control  muscular  spasm.  The  dose  employed 
.  was  30  gr.  hi  whisky  if  given  by  mouth,  in  hot  olive  oil  if  by  rectum. 
The  antispasmodic  effect  follows  either  method  with  nearly  the 
same  promptness  and  it  controls  the  spasm  wonderfully.  The 
dose,  or  a  smaller  one,  is  repeated  when  the  spasm  recurs;  of  the 
6  cases  reported  by  this  author,  5  recovered,  one  of  these  dying,  soon , 
after  recovery,  as  a  result  of  perforative  peritonitis. 

The  remaining  item  of  the  treatment  is  elimination  of  the  toxins. 
This  is  done  chiefly  by  administering  water  by  mouth,  by  rectum, 
subcutaneously,  or  intravenously. 

The  treatment  of  tetanus,  then,  may  be  summed  up  in  the 
following  brief  statements:  (1)  Remove  the  primary  focus,  or 
sterilize  it.  (2)  Neutralize  the  toxins  by  repeated  administration 
of  antitoxin.  (3)  Control  the  spasms,  preferably  with  chloroform, 
chloretone,  chloral,  or  morphin.  More  cures  follow  control  by 
chloral  or  chloretone.  (4)  The  injection  of  carbolic  acid.  (5) 
Keep  the  emunctories  active. 


CHAPTER  XII 
RABIES,  LYSSA,    HYDROPHOBIA 

RABIES  is  an  acute,  specific,  infectious  disease  produced  by  an 
unknown  cause,  transmitted  by  the  salivary  fluids  (usually)  of 
mammalia,  and  characterized  by  clonic  spasms,  a  rapid  course,  and 
a  fatal  termination. 

The  term  "hydrophobia"  is  applicable  only  to  rabies  in  man. 
Rallies  has  long  been  known  to  affect  both  animals  and  man,  but 
it  was  originally  thought  not  to  affect  man. 

Etiology. — The  actual  cause  is  unknown.  By  the  symptoms, 
tran<missibility,  and  the  fact  that  the  cause  can  be  destroyed  by 
sterilization,  light,  and  drying,  can  be  eliminated  from  contami- 
nated fluids  by  filtration  through  porcelain,  and  can  be  increased  in 
virulence  by  successive  inoculations  of  susceptible  animals,  it  is 
determined  unquestionably  to  be  a  parasite.  Whether  this  para- 
site is  bacterial  or  protozoic  remains  undecided;  however,  the  easy 
destruction  of  the  virus  by  quinin  solutions  have  led  some  to  con- 
clude that  the  etiologic  agent  is  a  protozoon. 

The  causative  agent  is  spoken  of  in  medical  literature  as  the 
vims  of  rabies.  It  is  found  in  the  saliva  and  salivary  glands  of 
animals  suffering  from  rabies,  and  for  twenty-four  to  forth-eight 
hours  prior  to  the  first  manifestation  of  symptoms.  The  virus  is 
also  found  in  the  saliva  of  man  during  the  course  of  the  disease, 
and  inoculation  of  animals  from  this  source  produces  the  disease. 
Hence,  although  there  are  no  cases  reported  in  which  man  has 
heroine  inoculated  from  man,  the  possibility  of  such  transmission 
mu-t  be  accepted  and  all  precautions  exercised  to  prevent  it.  The 
vims  is  found  also  in  certain  other  structures,  especially  the  central 
nervous  system.  It  has  occasionally  been  found  hi  the  milk. 

For  manifest  reasons  hydrophobia  usually  arises  from  bites, 
id  these  are  usually  made  by  the  dog,  owing  to  the  intimate  com- 
>anionship  between  man  and  dog.  The  percentage  of  bitten  indi- 
viduals who  develop  hydrophobia  is  small,  being  probably  between 
L5  and  20  per  cent.  The  bite  of  other  animals  belonging  to  the 

line  and  the  feline  species  is  responsible,  too,  for  a  considerable 
lumber  of  reported  cases,  and  the  percentage  of  infection  is  higher 
among  some  of  these  than  in  dog-bites.  The  highest  percentage  of 
inoculations  occurs  from  bites  of  the  wolf,  then  the  cat,  the  dog, 
and  other  animals.  The  explanation  of  the  small  percentage  of 
of  hydrophobia  resulting  from  bites  is  due  to  the  fact  that  the 

249 


250  PRINCIPLES   OF   SURGERY 

teeth  are  cleansed  in  passing  through  the  clothing,  and  to  the  possi- 
bility of  certain  suspected  animals  not  being  rabid. 

Bites  received  on  an  unprotected  surface  are  much  more  likely 
to  transmit  the  disease  than  those  through  clothing,  although  these 
are  sufficiently  dangerous.  The  worst  of  all  are  bites  on  the  face. 
It  is  not  necessary  that  the  teeth  should  penetrate  the  skin;  abra- 
sion of  the  epithelium  is  sufficient;  however,  lacerated  wounds  are, 
for  obvious  reasons,  more  dangerous. 

The  virus,  when  once  deposited  in  the  tissues,  travels  along  the 
course  of  the  nerves  to  the  centers,  and  remains  there  for  some 
indefinite  tune  before  symptoms  arise.  The  virus  may  remain 
confined  to  the  side  bitten.  This  is  the  rule  in  cases  with  a  short 
period  of  incubation.  In  cases  whose  period  of  incubation  is  longer 
the  virus  crosses  to  the  side  opposite  the  bite,  and  may  be  found 
distributed  throughout  the  central  and  peripheral  nerve  structures 
of  the  body. 

Severance  of  a  nerve  prevents  spread  of  the  virus  past  the 
severed  point.  For  example,  severance  of  the  cord  prevents  ex- 
tension of  the  virus  from  the  upper  to  the  lower  segment,  or  vice 
versa. 

Destruction  of  Virus. — The  virus  of  rabies  is  destroyed  by  ex- 
posure to  heat  and  cannot  withstand  60°  C.  longer  than  thirty 
minutes.  Cold  does  not  damage  the  virus,  but  seems  rather  to 
preserve  it.  It  is  preserved  in  neutral  glycerin  for  an  indefinite 
period,  preferably  at  a  low  temperature.  Drying  of  the  virus  or  of 
the  tissues  containing  it  destroys  its  virulence  directly  in  proportion 
to  the  length  of  time  it  is  dried,  until,  by  the  end  of  fourteen  or 
fifteen  days,  the  virulence  becomes  nil.  Pasteur  based  the  treat- 
ment for  prevention  of  hydrophobia  on  this  fact.  If  the  tissues. 
containing  the  virus  during  the  process  of  drying  are  in  very  small 
pieces  or  in  thin  slices  the  virus  is  destroyed  in  a  few  days.  Sun- 
light destroys  the  virus  in  forty  hours. 

A  practical  observation  should  be  made  here  concerning  the 
carcasses.  All  animals  dying  of  hydrophobia  should  be  destroyed 
by  burning,  not  by  burial,  as  the  environment  of  the  buried  body 
is  such  as  to  maintain  the  inoculability  of  the  virus  indefinitely, 
and  other  animals  preying  on  these  dead  bodies  are  likely  to  develop 
the  disease.  Furthermore,  the  presence  of  such  bodies  may  con- 
taminate surface  water,  in  which  the  virus  may  continue  to  live 
for  some  weeks. 

The  usual  antiseptic  drugs — bichlorid  of  mercury,  carbolic- 
acid,  and  formaldehyd — destroy  the  virus.  It  is,  furthermore, 
destroyed  by  solutions  of  uric  acid,  1  : 16,  and  by  bile. 

Pathology. — The  pathologic  changes  found  in  subjects  dying 
of  hydrophobia  are  few  and  inconstant.  Most,  if  not  all,  of  the 


RABIES,    LYSSA,    HYDROPHOBIA  251 

changes  result  from  the  spasms  and  are  not  characteristic. 
The  vi-cera,  both  thoracic  and  abdominal,  show  congestion.  This 
i>  more  frequent  in  the  kidneys,  spleen,  and  lungs.  Emphysema 
may  be  present.  The  fauces,  larynx,  pharynx,  and  esophagus  are 
usually  observed  to  be  congested. 

In  the  brain  and  spinal  cord  there  is  a  general  hyperemia  and 
inflammatory  foci,  some  hemorrhagic,  others  white  and  soften- 
ini:.  which  are  said  to  resemble  those  found  in  poliomyelitis 
(  Kaufmann).  Leukocytes  may  accumulate  at  these  foci  until  they 
iv-emMe  miliary  abscesses.  These  changes  are  not  uniformly 
distributed  throughout  the  central  nervous  system,  but  affect 
cert  ain  >t  ructures  more  intensely.  Of  these,  the  medulla  oblongata 
shows  the  most  marked  changes.  Embryonic  cells  are  found 
accumulated  around  the  central  canal  and  in  the  motor  centers  of 
the  cord.  When  these  embryonal  cells  accumulate  around  a  cell 
the  latter  degenerates,  and  its  space  is  occupied  by  the  embryonal 
cells,  constituting  the  embryonal  tubercle. 

Another  finding  is  Negri  bodies.  Their  nature  is  not  known. 
Some  (including  Negri)  have  thought  them  to  be  the  causative  or- 
ganisms of  hydrophobia,  others  consider  that  they  are  encapsulated 
micro-organisms  lying  within  the  cells.  They  are  constant  and  are 
found  most  abundantly  in  the  horn  of  Ammon  (pes  hippocampi). 
Their  discovery  is  the  best  and  quickest  method  for  microscopic 
diagnosis  of  rabies.  These  bodies  appear  only  in  this  disease,  re- 
main throughout,  and  are  not  affected  by  processes  of  decomposi- 
tion subsequent  to  death.  The  specimen  should  be  procured  from 
the  cerebral  cortex  or  pes  hippocampi.  They  may  be  present  at 
one  site,  while  absent  from  another.  They  are  found  in  large 
numbers  in  the  cerebellum,  and  with  less  frequency  in  the  medulla 
and  the  spinal  cord  and  its  ganglia. 

RABIES   IN  THE   DOG 

Since  dogs  are  the  chief  distributors  of  hydrophobia,  it  is 
ne< •» ->sary  that  as  wide  knowledge  as  possible  of  rabies  in  dogs 
should  be  distributed.  The  disease  has  been  practically  if,  indeed, 
n..t  entirely,  as  Knglish  physicians  claim,  eradicated  from  Great 
Britain  by  ri^id  methods  of  handling  the  dogs.  The  large  cities 
of  other  countries — Vienna  is  an  example — allow  no  dogs  the  free- 
dom of  the  erects  unless  they  wear  muzzles.  In  all  cases  where 
rabies  develops  among  the  lower  animals,  especially  among  dogs  hi 
the  cities,  it  should  lie  compulsory  to  confine  or  muzzle  all  dogs 
until  a  satisfactory  period  el.-ip-.-. 

Symptoms.  The  period  of  incubation  in  the  dog  varies  from 
three  to  five  week-.  During  the  onset  the  do<;'<  nature  changes 
and  he  becomes  restless,  excitable,  and  irritable.  There  is  loss  of 


252  PRINCIPLES   OF   SURGERY 

appetite,  a  desire  for  indigestible  material,  such  as  sticks,  grass, 
or  earth,  and  the  presence  of  these  in  the  stomach  with  absence  of 
food  is  a  significant  fact.  Nausea  may  appear  and  dysphagia  is 
present.  The  dog  ceases  to  be  playful  and  affectionate  and  is  no 
longer  obedient.  He  may  be  quiet  or  howl  and  bark  at  imaginary 
objects.  I  have  known  a  hydrophobic  bitch  with  young  puppies 
to  manifest  the  change  first  by  whipping  the  puppies  away  and 
refusing  to  suckle  them.  This  stage  lasts  from  one  to  three  days, 
and  is  the  most  dangerous  one,  owing  to  failure  hi  recognizing  the 
true  condition. 

The  second  stage,  that  of  excitement  or  of  raging  madness,  usu- 
ally follows,  although  occasionally  the  second  stage  is  wanting  and 
the  prodromal  stage  is  followed  directly  by  the  paralytic.  The  dog 
becomes  utterly  unable  to  control  himself,  runs  about  restlessly, 
bites  or  snaps  at  everything  that  disturbs  him,  and  may  simply 
snap  at  imaginary  objects.  He  wanders  aimlessly.  Emaciation 
is  rapid.  |The  frothing  at  the  mouth,  so  deeply  significant  to  the 
laity,  is  not  constant,  but  inability  to  drink  is  marked,  owing  to 
pharyngeal  spasms.  Ropy  saliva  runs  from  the  mouth  on  this 
account.  The  bark  is  hoarse  and  unnatural.  This  is  followed  in 
two  or  three  days  by  evidences  of  paralysis,  which  begins  in  the 
hind  legs  and  gradually  ascends  till  death  ensues,  preceded  by  con- 
vulsions. 

When  the  paralytic  stage  follows  the  prodromal  stage  the 
symptoms  just  described  may  be  wanting.  The  dog  shows  par- 
alysis of  the  muscles  of  mastication,  indicated  by  dropping  of  the 
lower  jaw,  a  sign  accepted  as  pathognomonic  by  veterinarians, 
and  paralysis  of  the  extremities  and  muscles  of  deglutition;  this 
is  more  rapid  in  its  course  than  those  cases  in  which  the  stage  of 
excitement  is  present.  This  is  known  also  as  dumb  rabies. 

HYDROPHOBIA   IN   MAN 

The  period  of  incubation  in  man  varies  widely.  The  average 
tune  is  six  weeks.  The  minimum  period  of  incubation  is  about 
two  weeks  and  the  maximum  is  one  hundred  and  eighty  days; 
occasionally  the  disease  has  been  reported  to  occur  as  late  as  one 
year  or  more,  but,  if  this  is  possible,  it  is  certainly  very  rare. 

Prior  to  the  onset  of  hydrophobia  there  may  be  certain  pre- 
monitory symptoms.  The  patient  is  uneasy  and  the  scar  may 
become  reddened  and  itch  or  burn.  If  the  wound  has  not  healed 
the  granulation  tissue  assumes  an  unhealthy  appearance.  Pain 
may  be  present  in  the  scar  or  wound  and  in  the  region  supplied  by 
the  same  nerve.  The  local  symptoms  may  antedate  the  disease 
several  days. 

Stages. — Three    stages    of    hydrophobia    are    described — the 


RABIES,    LY8SA,    HYDROPHOBIA  253 

premonitory,  or  first  stage;  the  stage  of  excitement,  or  second  stage; 
tin-  paralytic,  or  third  stage. 

The  Premonitory  Stage. — This  stage  is  characterized  by  the 
-y,  restless  condition,  and  the  feeling  of  some  impending 
evil.  The  patient  feels  and  looks  anxious;  his  disposition  changes, 
and  he  is  easily  irritated  or  becomes  melancholic.  The  sensorium 
is  hyj>ersusceptible  to  stimuli,  as  is  shown  by  the  presence  of  marked 
hyprresthesia.  Photophobia  may  be  present.  The  patient's  at- 
tention cannot  be  concentrated,  the  mind  wandering  easily  from 
t  he  s  ubj  ect.  Sleeplessness  intervenes.  Then  the  beginning  spasms 
are  indicated  by  disturbance  of  the  pharyngeal  and  laryngeal  mus- 
cles first.  The  patient  cannot  eat  or  drink  satisfactorily;  he 
si  nu  igles  or  chokes  easily  and  has  no  appetite.  The  voice  becomes 
hu-ky  and  malaise  comes  apace.  There  is  precordial  distress. 
The  mental  symptoms  become  more  intense  and  the  individual 
continues  to  grow  more  and  more  unlike  himself,  until  delusions 
an*  1  mania  appear  toward  the  end  of  this  stage.  At  times  disposed 
to  talk  excessively,  at  others  he  seeks  solitude  and  silence.  This 
stage  continues  for  from  eighteen  to  forty-eight  hours. 

The  Stage  of  Excitement. — The  symptoms  gradually  increase 
in  severity  and  the  spasms  in  extent,  and  the  whole  appearance 
becomes  that  of  one  gone  mad.  The  face  is  wild  looking  and 
is  pale.  Irritation  of  the  skin  and  stimulation  of  the  auditory 
nerve  causes  dilatation  of  the  pupils.  The  whole  appearance 
is  one  of  tension,  the  muscles  are  drawn  and  uneasy.  The 
spasms  of  the  first  stage  are  increased  hi  intensity,  frequency, 
ami  ease  of  provocation.  Every  attempt  to  swallow  either  food 
or  drink  induces  the  spasm,  and  a  sense  of  suffocation  comes 
over  the  patient;  dyspnea  is  present  during  the  spasms;  on 
account  of  the  inability  to  swallow,  the  saliva  accumulates 
and  runs  in  strings  from  the  mouth.  Thirst  is  intense  and 
insatiable  from  inability  to  swallow,  the  fluids  attempted  being 
forcibly  spurted  from  the  mouth.  Vomiting  is  sometimes  ob- 
served. The  spasms  gradually  involve  more  of  the  voluntary 
niu-eles  until  they  become  general.  They  are  usually  described  as 
clonic,  but  they  may  resemble  those  of  tetanus,  even  the  rather 
characteristic  posture  of  opisthotonos  being  assumed.  The  sen- 
sorium  becomes  increasingly  susceptible,  and  the  least  noise, 
especially  that  produced  by  splashing  or  running  of  water,  the 
very  si^ht  or  suggestion  or  thought  of  water  or  anything  resembling 
it.  the  gent le-t  touch,  the  tiniest  ray  of  light ,  will  throw  the  patient 
into  a  convulsion.  All  normal  reflexes  are  increased  until  the  cor- 
tical (enters  of  the  brain  become  affected;  the  pupils  remain  dilated, 
normal  reflexe>  disappear,  and  control  of  the  vesical  sphincters  is 
lost.  The  length  of  the  attack-  increa.-cs,  and  they  are  relaxed  by 


254  PRINCIPLES   OF   SURGERY 

sheer  exhaustion.  The  respiratory  muscles  are  involved,  and  res- 
piration, therefore,  suspended  until  the  spasm  relaxes.  On  this 
account  death  may  occur  during  this  stage.  The  mental  suffering 
is,  from  all  appearances,  as  marked  between  the  attacks  as  the 
physical  is  during  their  continuance.  The  dread  of  each  succeed- 
ing attack,  with  its  torturing  pain  and  violent  exercise  of  sore 
muscles,  haunts  the  patient  during  the  interval.  He  is  lucid  be- 
tween attacks,  unless  the  cerebrum  is  especially  involved,  when 
delirium  occurs  and  persists. 

The  temperature  changes  are  inconstant  and  unimportant. 
The  temperature  rises  during  the  first  stage  and  continues  through- 
out the  disease.  Its  range  is  from  100°  to  105°  F.  As  in  tetanus, 
so  here  there  may  be  a  postmortem  rise  of  temperature.  The 
pulse  is  rapid  and,  with  the  approach  of  exhaustion,  becomes  very 
feeble  and  frequently  irregular.  Priapism,  with  its  attendant  dis- 
comforts, is  usually  observed,  and  desire  for  sexual  intercourse  may 
be  marked  and  annoying.  Unprovoked  emissions  sometimes  occur. 

The  second  stage  lasts  two  or  three  days. 

The  Paralytic  Stage. — A  short  while  prior  to  death,  usually  less 
than  one  day,  the  spasms  subside,  the  mental  symptoms  disappear, 
and  the  patient  and  his  attendants  are  likely  to  consider  him  better 
and  perhaps  on  the  road  to  recovery.  Not  so;  it  is  the  beginning 
of  the  terminal,  fatal,  paralytic  stage.  The  paralysis  begins  near 
the  part  bitten,  and  gradually,  but  rapidly,  spreads  till  it  becomes 
general,  and,  finally,  on  reaching  the  vital  centers,  death  comes; 
unless,  indeed,  as  is  usually  the  case,  death  with  or  without  coma 
comes  from  exhaustion. 

The  paralytic  stage  may  follow  the  prodromal  symptoms  and  no 
spasms  occur.  This  is  more  likely  to  follow  a  large  wound,  or  large 
doses  of  virus,  and  when  the  atrium  is  on  the  lower  extremity. 
Paralysis  usually  begins  in  the  region  of  the  bite,  but  may  start  in 
the  lower  extremities  as  a  paraplegia.  The  paralysis  ascends 
rapidly,  all  muscles  supplied  by  the  cord  are  involved,  and  death 
supervenes  when  a  vital  center  is  reached.  In  this  type  swallow- 
ing is  possible.  The  duration  of  the  paralytic  type  is  usually 
shorter  than  the  raging  (two  to  five  days),  but  death  may  not 
occur  before  the  seventh  day. 

Diagnosis. — Hydrophobia  must  be  differentiated  from  tetanus, 
acute  mania,  hysteria,  and  lyssophobia  or  pseudophobia.  The 
differentiation  in  any  of  these  instances  should,  under  ordinary  cir- 
cumstances, be  made  without  difficulty  if  the  history  of  the  case 
and  the  symptoms  be  considered  carefully.  On  the  other  hand, 
the  need  for  such  a  differentiation  is  growing  less  frequent,  owing 
to  the  preventive  means  employed.  There  are  but  a  small  per- 
centage of  physicians  of  the  present  day  who  have  had  the  opportu- 
nity to  study  a  case  of  hydrophobia  in  man. 


RABIES,    LYSSA,    HYDROPHOBIA  255 

A  much  more  important  study,  therefore,  is  that  enabling  us 
to  recognize  hydrophobia  in  animals  which  have  bitten  an  individ- 
ual. The  first  fact  to  be  remembered  in  such  cases  is  that  it  is 
at  >-<  »lutely  necessary  that  the  dog  (or  cat)  should  not  be  killed  after 
producing  a  bite  unless  an  unmistakable  diagnosis  has  been  made, 
and  in  the  vast  majority  of  cases  this  is  impossible  at  the  time  of  the 
biting,  owing  to  the  greater  frequency  of  such  occurrence  during 
t  he  earlier  stages  of  rabies.  The  animals  should,  therefore,  be  con- 
fined, preferably  by  a  competent  veterinarian,  until  the  disease 
has  had  time  to  develop.  If  it  fails  to  show  positive  symptoms  of 
rabies  within  forty  days  the  patient  can  be  dismissed  without 
preventive  treatment.  If  the  animal  develops  a  disease,  but 
recovers,  this  may  be  accepted  as  positive  evidence  that  the  disease 
i>  not  rabies.  The  shorter  period  of  incubation  in  the  dog,  and  the 
fact  t  hat  the  disease  must  be  practically  beginning  to  develop  before 
inoculation  can  occur,  and,  on  the  other  hand,  the  long  incubation 
period  in  man,  renders  it  safe  to  wait  for  this  information.  If  the 
animal  is  killed  at  the  time  of  the  bite,  as  is  too  often  the  case,  then 
the  animal  should  be  turned  over  to  a  competent  pathologist,  or 
proper  parts  of  the  central  nervous  tissues  should  be  placed  in 
neutral  glycerin  and  sent  to  the  pathologist;  it  is  immaterial  if  the 
animal  has  been  dead  long  enough  for  decomposition  to  be  well 
advanced,  the  Negri  bodies  can  still  be  found.  Fortunately,  they 
appear  early  in  the  tissues  and  remain  intact  long  after  decomposi- 
tion begins. 

Prognosis. — The  prognosis  of  hydrophobia  is  hopeless — no 
cases  recover.  However,  the  means  of  prevention  are  almost 
equally  sure  if  the  possibility  of  hydrophobia  is  recognized  at  the 
time  of  the  bite.  Just  what  percentage  of  individuals  bitten  by 
rabid  dogs  develop  the  disease  is  uncertain,  but  it  is  probably 
1  >et  \veen  15  and  20  per  cent,  where  no  preventive  treatment  is  used. 
It  i-  higher  in  wounds  of  exposed  surfaces,  the  hands,  the  face,  and 
the  bare  legs,  and  lower  in  wounds  of  parts  covered  by  clothing; 
higher  in  wounds  produced  by  wolves  and  cats;  higher  in  large 
lacerated  or  deep  wounds;  lower  in  superficial  wounds  and  in  abra- 
sions. If  preventive  treatment  is  done  by  amputation  the  number 
of  cases  of  hydrophobia  is  reduced  ^  of  1  per  cent. 

Treatment. — Prophylaxis. — In  all  cases  where  bites  have  been 
made  by  Auspicious  animals,  or  where  saliva  from  the  mouths  of 
such  has  come  into  contact  with  a  wound  or  ulcer,  as  in  those  who 
permit  dogs  to  lick  their  hands  and  faces,  the  wound  and  the  sur- 
rounding area  should  be  anti>eptici/ed  either  by  the  application  of 
strong  bichlorid  of  mercury  solutions  or  carbolic  acid,  or  by  the 
application  of  the  actual  cautery,  which  i<  preferable.  The  longer 
the  time  intervening  between  the  infliction  of  the  bite  and  such 


256  PRINCIPLES   OF   SURGERY 

treatment,  the  greater  the  probability  of  failure.  If,  however,  such 
a  method  is  employed  early  and  thoroughly  it  can  scarcely  fail  to 
prevent  the  development  of  hydrophobia. 

It  is  the  rule  now,  and  its  application  has  almost  abolished 
hydrophobia  in  intelligent  communities,  to  recommend  all  persons 
bitten  by  rabid  animals  to  take  the  Pasteur  treatment.  The 
inability  of  many  patients  to  reach  the  laboratories,  if  distant,  and 
to  pay  for  the  treatment,  and  the  poor  provisions  of  most  cities 
for  handling  such  cases,  renders  it  often  necessary  to  forego  this 
treatment  and  to  trust  to  antiseptic  treatment. 

Pasteur  Treatment. — So  far  as  has  been  learned  from  the 
many  thousands  of  cases  immunized  by  this  plan,  one  may  conclude 
that  the  treatment  is  absolutely  devoid  of  risk  of  producing  hydro- 
phobia, unless  those  who  develop  the  disease  hi  spite  of  treatment 
are  considered  to  receive  their  infection  from  this  source. 

The  Pasteur  treatment  for  prevention  of  hydrophobia  in  in- 
dividuals who  have  been  inoculated  consists  in  the  gradual  im- 
munization by  administering  virus  attenuated  by  drying,  and  at 
each  succeeding  dose  giving  a  less  attenuated  virus  until  the  body 
is  immunized  against  the  disease.  The  plan  is  very  simple — the 
spinal  cords  of  hydrophobic  rabbits  are  dried,  and  the  initial  dose 
is  made  from  a  cord  that  has  been  dried  fourteen  days,  and  thus 
reduced  to  the  lowest  virulence,  the  second  dose  is  given  from  one 
dried  thirteen  days,  and  so  on  until  the  last  doses  are  made  from 
a  fresh  cord.  The  treatment  is  administered  hypodermically,  as 
an  emulsion  in  neutral  glycerin.  The  following  scheme  will  illus- 
trate the  plan  of  treatment: 

Day  of  treatment 1     2    3    4     5    6    7    8    9  10  11  12  13  14 

Number    of    days    cord    was 

dried 1413121110     987654321 

If  a  sufficient  number  of  days  have  elapsed  before  the  beginning 
of  treatment  to  demand  haste  alternate  doses  may  be  skipped,  and 
only  odd  doses  given,  or  a  dose  may  be  administered  each  morning 
and  evening.  Thus,  the  number  of  days  of  treatment  may  be  re- 
duced by  half.  It  is  important  to  state  here  that  the  emulsions 
employed  for  treatment  may  now  be  ordered  directly  from  the 
manufacturer  by  the  attending  physician. 

The  treatment  of  hydrophobia,  as  such,  has  proved  to  be  a  fruit- 
less task.  After  the  disease  develops  the  Pasteur  treatment  is  of 
no  more  value  than  any  other,  and  all  that  the  physician  in  charge 
can  do  is  to  control  the  spasm  by  quietude,  darkness,  antispas- 
modics,  anodynes,  and  anesthetics.  Unlike  tetanus,  the  disease 
kills  independently  of  the  spasms,  and,  even  if  they  are  controlled, 
life  is  not  prolonged  by  treatment. 


CHAPTER  XIII 

ANTHRAX,  WOOL-SORTERS'  DISEASE,  MALIGNANT  PUS- 
TULE, CHARBON 

ANTHRAX  is  an  acute  infectious  disease  produced  by  the  Bacillus 
anthracis,  and  appearing  either  as  an  external  surgical  lesion,  or  as 
an  internal  medical  disease. 

Etiology. — The  cause  of  anthrax  is  the  Bacillus  anthracis,  a 
widely  distributed  micro-organism,  habitually  forming  spores 
which  are  very  resistant  to  bactericidal  agents,  and  pass  unharmed 
through  the  stomach,  although  the  bacteria  are  destroyed  by  the 
^a-tric  juice.  This  bacterium  was  the  first  discovered  of  the  large 
number  of  pathogenic  germs.  They  are  widely  distributed,  are 
found  especially  in  soil  and  on  the  products  of  the  soil.  Once  they 
gain  a  hold  upon  the  soil  they  are  with  difficulty  eradicated.  In 
many  regions  endemic  new  territory  is  invaded  by  the  blood  and 
fle.-h  of  dead  animals,  or  by  contaminated  water,  such  as  the  waste 
from  tanneries  flowing  over  the  ground.  From  the  soil,  grass,  and 
hay  animals  are.infected,  chiefly  herbivora,  occasionally  carnivora; 
and  from  these  animals  and  their  products,  flesh,  blood,  hides,  hair, 
and  wool,  man  becomes  infected,  often  in  parts  of  the  world  remote 
from  the  nativity  of  the  animal.  The  most  dangerous  countries 
art-  the  continent  of  Europe,  South  America,  China,  and  South 
Africa;  occasionally  small  outbreaks  are  seen  in  the  United  States. 
Hides,  wool,  and  hair  from  these  countries,  especially  from  Russia 
and  China,  are  the  chief  sources  of  the  disease  among  workmen. 
Hence,  tho-c  who  work  in  tanneries,  woolen  mills,  and  manufac- 
turers of  hair  products,  butchers,  and  occasionally  farmers,  in  dis- 
tricts where  the  disease  is  endemic,  are  infected. 

Milk  from  infected  animals  may  convey  the  disease.  The 
external  form  may  be  contracted  from  any  infected  material,  the 
internal  more  especially  from  materials  which  are  dry  and  free  from 
urea-!-.  Flies  and  fleas  may  communicate  the  infection. 

The  bacillus  of  anthrax  retains  its  vitality  indefinitely  in  the 
soil,  and  is  not  reduced  in  virulence  or  activity  by  the  ordinary 
processes  of  manufacture,  such  as  tanning.  The  mode  by  which 
anthrax  infection  produces  disease  is  not  known,  no  toxin  having 
been  discovered.  It  is  antagonized  by  admixture  of  staphylococci 
and  -treptoeocci  and  destroyed  by  Bacillus  pyocyaneus.  When 
it  is  caused  to  grow  at  temperature  above  42°  C.  it  becomes  attenu- 

17  257 


258  PRINCIPLES    OF   SURGERY 

ated,  and  has  been  used  in  this  form  for  immunization  of  animals  by 
injecting  it  in  conjunction  with  an  anti-anthrax  serum.  Pasteur's 
plan  for  attenuation  of  the  bacteria  for  immunity  was  to  cultivate 
the  first  injection  twenty-four  days  and  the  second  twelve  days 
at  the  above  temperature. 

Pathology.— The  morbid  changes  found  hi  cases  dying  of  an- 
thrax are  not  of  very  great  clinical  interest.  Hemorrhages  into  the 
viscera  and  ecchymoses  of  the  serous  surfaces,  especially  of  the 
heart  and  lungs,  occur.  Cloudy  swelling  of  the  spleen  and  liver  and 
enlargement  of  these  organs  is  seen.  The  lymph-nodes  are  enlarged 
in  the  region  affected,  the  bronchial  nodes  being  especially  affected. 
They  contain  a  fibrinohemorrhagic  exudate.  There  are  effusions 
hi  the  omentum  and  extraperitoneal  tissue,  and  hydrothorax  and 
effusion  into  the  pericardium  are  frequent.  The  fluid  may  be 
serous  or  occasionally  bloody. 

The  stomach  and  intestines  may  show  inflamed  masses,  which 
break  down  and  resemble  the  carbuncle  of  the  external  type  of 
anthrax.  In  the  pulmonary  type  the  lungs  become  edematous  and 
the  alveoli  fill  up  with  a  fibrinous  exudate,  which  may  be  bloody  and 
conform  to  the  type  either  of  lobar  or  lobular  pneumonia. 

The  bacilli  are  recoverable  from  the  blood  in  general  infections, 
which  occur  more  frequently  from  the  internal  than  from  the 
external  type. 

Soon  after  death  the  body  becomes  very  dark  and  decomposition 
sets  in  early. 

The  External  Type. — This  manifests  itself  hi  the  malignant  pus- 
tule which  occurs  at  the  site  of  the  atrium.  The  period  of  incuba- 
tion is  from  one  to  three  days.  A  local  inflammation  begins  as  a 
small  livid  speck,  which  rapidly  enlarges  and  becomes  red  or  yellow- 
ish. The  lump  may  reach  the  maximum  size  of  a  hen's  egg.  Over 
its  surface  a  bleb  forms,  which  contains  a  clear  watery  fluid  or  a 
sanioserous  fluid.  This  ruptures,  the  fluid  escapes,  and  the  in- 
flamed central  portion  turns  black,  becomes  necrotic,  and  from  be- 
neath it  a  discharge  comes  which  contains  the  specific  bacilli. 
The  discharge  is  purulent  only  in  cases  of  secondary  pyogenic  in- 
fection. The  necrotic  mass  or  scab  seems  to  sink  down  so  that  a 
wall  is  left  surrounding  it.  In  the  region  immediately  surrounding 
the  pustule,  either  on  normal  skin  or  an  infiltrated  inflamed  area,  a 
number  of  ring-like  vesicles  form,  and  contain  either  a  clear,  bluish- 
red,  or  yellowish  fluid.  The  lymphatics  are  occasionally  involved. 
The  malignant  pustule  is  the  most  frequent  type  of  anthrax  in  man, 
and  usually  appears,  for  obvious  reasons,  on  the  hands,  forearms, 
or  face. 

At  the  beginning  the  patient  complains  of  burning  or  itching 
at  the  site  of  infection;  beyond  this  the  pustule  is  and  remains 


ANTHRAX  259 

free  from  pain,  but  shows  tenderness  on  pressure.  As  the  case 
progresses  the  necrotic  central  mass  increases  in  size,  reaching 
soi n< -times  the  diameter  of  an  inch.  Edema  appears  around  the 
pustule,  and  may  extend  to  remote  limits,  affecting  the  whole 
hea<  1  and  neck  or  an  entire  extremity.  The  edematous  surrounding 
area  is  hard  and  brawny. 

The  general  symptoms  produced  by  malignant  pustule  bear 
no  definite  relationship  to  the  extent  or  intensity  of  the  local 
le>ioii.  They  may  be  wanting  entirely,  they  may  appear  in  the 
tir-t  twenty-four  hours,  or  only  after  a  week  or  more.  At  first 
the  constitutional  symptoms  are  those  of  infection  in  general — 
malaise,  headache,  loss  of  appetite,  perhaps  nausea  and  vomiting, 
an<  1  rigor  or  chilliness.  The  temperature  is  variable  and  ordinarily 
of  no  significance.  It  may  be  high  in  mild,  low  hi  severe,  cases  of 
external  anthrax.  The  pulse  is  accelerated  and,  as  the  patient 
grows  worse,  becomes  irregular  and  weak.  Symptoms  of  exhaus- 
tion appear  as  the  disease  advances;  cyanosis  and  increased  respira- 
tion occur,  vomiting  and  diarrhea  may  be  violent,  and  the  stools 
are  foul.  The  restlessness  of.the  beginning  may  be  succeeded  by 
convulsions  or  delirium,  and  coma  may  develop,  although  the  mind 
u-ually  remains  clear  to  the  end,  which  may  come  gradually  from 
exhaustion  or  suddenly  and  without  warning.  In  the  fatal  cases 
death  usually  comes  within  a  week,  but  in  very  severe  cases  it  may 
con  if  within  thirty-six  to  forty-eight  hours. 

Anthrax  Edema. — Occasionally  anthrax  manifests  itself  far 
differently  from  the  lesion  described  above,  showing  as  its  chief 
characteristic  an  extensive,  brawny,  edematous  swelling,  the  sur- 
f;i. ,  of  which  may  show  evidence  of  the  underlying  inflammation, 
and  the  com  lit  ion  may  be  confused  with  erysipelas.  It  is  sometimes 
called  anthrax  erysipelas.  The  infection  in  an  anthrax  edema  is 
not.  as  in  malignant  pustule,  confined  in  the  cutaneous  tissue,  but 
has  hem  admitted  into  the  connective  tissue  of  the  region  attacked. 
The  primary  eschar  is  often  wanting,  and  the  edematous  tissue  has 
a  translucent  appearance.  On  incision  into  the  tissues  they  appear 
to  l>e  filled  with  a  more  or  less  gelatinous  substance,  rather  than 
,-ith  watery  fluid  of  ordinary  edema. 

Hid.-  may  form  on  the  surface,  and  when  they  rupture  are 
followed  Ity  the  characteristic  dry  eschar.  Anthrax  edema  is 
s,  but  it  is  very  rapid,  and  is  much  more  fatal  than  malig- 

it  pu>tule.  Anthrax  edema  is  often  associated  with  malignant 
)u>tule  of  the  face.  In  this  type,  as  in  the  preceding,  the  lymphat- 
•s,  node-,  and  vessels  are  affected,  showing  the  usual  changes  of 
lymphangitis  ami  lymphadenitis  in  extreme  development. 

General  Infection. — The  non-surgical  forms  of  anthrax,  known 
as  internal  anthrax,  do  not  concern  us  here.  They  may  be  intes- 


260  PRINCIPLES   OF   SURGERY 

tinal  (mycosis  intestinalis),  pulmonary  anthrax  (wool-sorters' 
disease),  or  anthracemia.  The  symptoms  of  a  violent  infection 
develop,  either  with  no  previous  warning  or  with  the  ordinary 
prodromal  evidence  of  a  beginning  infection,  and  rapidly  run  their 
course  to  a  fatal  termination;  at  times  death  comes  by  collapse  hi 
two  days  or  less  from  the  beginning.  In  the  pulmonary  type  the 
lungs  are  more  prominently  called  to  attention,  and  in  the  intes- 
tinal type  gastro-intestinal  symptoms  predominate;  but,  while  the 
involvement  of  these  organs  is  respectively  emphasized,  yet  the 
general  condition  is  one  of  extreme  intoxication  and  prostration. 
The  temperature  is  rarely  very  high. 

Diagnosis. — Anthrax  can  usually  be  recognized  with  little 
difficulty  if  it  is  thought  of.  The  danger  is  that  it  will  escape  with- 
out diagnosis  when  only  occasional  sporadic  cases  are  seen.  In  the 
external  types  the  bacilli  are  easily  discovered  in  the  fluid  of  the 
blebs,  but  they  are  more  difficult  to  find  after  the  lapse  of  a  week 
or  after  the  occurrence  of  pyogenic  infection.  In  malignant  pustule 
the  appearance  of  the  primary  lesion,  with  the  central  bleb  and  the 
surrounding  zone  of  small  vesicles  .on  an  inflamed  base,  and  the 
subsequent  formation  of  an  eschar,  is  characteristic.  In  pulmonary 
anthrax  the  characteristic  bacteria  may  be  recovered  from  the 
sputum,  and  in  mycosis  intestinalis  from  the  feces.  The  absence 
of  pain  in  so  violent  an  inflammatory  lesion  as  external  anthrax 
should  cause  search  for  the  bacilli,  as  hi  the  ordinary  pyogenic 
infections  of  similar  appearance,  such  as  phlegmonous  erysipelas 
and  carbuncle,  pain  is  a  very  prominent  symptom.  The  occupar 
tion  of  individuals  manifesting  suspicious  symptoms  should  always 
be  inquired  into  specifically. 

Complications. — When  anthrax  develops  as  a  local  or  external 
process  there  is  always  danger  of  its  becoming  general,  or  of  metas- 
tases,  especially  of  the  larger  viscera,  developing.  When  the 
lungs  are  affected,  or  when  the  edematous  type  occurs  hi  the  face 
or  neck,  edema  of  the  glottis  is  likely  to  hasten  the  end. 

Prognosis. — The  outlook  in  all  cases  of  anthrax  is  grave  enough. 
In  the  internal  forms  the  fatal  cases  may  reach  as  high  as  80  per 
cent.  In  external  anthrax  the  prognosis  is  materially  modified 
by  the  site  of  the  primary  lesion.  Broadly  speaking,  the  nearer 
the  malignant  pustule  to  the  face,  the  greater  the  mortality;  the 
mortality  in  these  cases  ranges  from  20  to  30  per  cent.  Lesions 
on  the  neck  and  eyelids  are  the  most  dangerous.  Those  on  the 
upper  extremity  have  a  mortality  about  half  that  of  lesions  on  the 
face  and  neck,  and  those  of  the  lower  extremities  about  half  that 
of  the  upper. 

Those  cases  which  show  marked  febrile  reaction,  or  an  active 
inflammation  locally,  are  more  favorable  than  those  in  which  the 


ANTHRAX  261 

reliction  is  slight.  The  quality  and  rate  of  the  pulse  is  important. 
A  moderate  pulse-rate,  with  good  volume,  is  favorable,  while  a 
weak,  rapid,  or  irregular  pulse  is  usually  followed  by  death.  Bell 
(quoted  by  Ravenel)  says  the  pulse  is  the  best  guide. 

Treatment. — Prophylaxis. — All  animals  dying  of  anthrax 
should  be  totally  destroyed  by  burning.  No  part,  such  as  the 
hiiles,  should  be  used,  for  the  danger  of  skinning  the  carcass  is 
manifest.  If  cremation  is  impracticable,  the  body  should  be 
buried  deeply,  beyond  the  danger  of  vermin  infecting  the  soil  from 
it.  The  barns  and  stables  which  harbored  the  animal  must  be 
disinfected  under  skilled  direction — -it  is  a  difficult  procedure. 
The  appearance  of  the  disease  in  a  herd  of  animals  demands  isola- 
tion of  the  diseased  ones  and  immunization  of  the  healthy  ones  by 
injection  of  serum.  The  rules  of  asepsis  and  isolation  are  to  be 
executed  rigidly  by  those  in  attendance  upon  anthrax  patients,  and 
subsequent  sterilization  of  the  apartments  must  be  complete. 
Man  has  been  successfully  immunized  by  injecting  serum. 

1  7 /re  Treatment. — The  first  principle  to  impress  in  the  treat- 
ment of  external  anthrax  is  that  the  infection  is  much  more  uni- 
formly limited  to  the  local  primary  lesion  in  man  than  in  animals, 
and  that,  therefore,  nothing  shall  be  done  by  way  of  treatment 
which  can  vitiate  or  reduce  this  natural  protection.  It  has  been 
shown  that  the  plans  formerly  employed,  of  excision  or  cauteriza- 
tion, rendered  the  dislodgment  of  the  bacteria  from  the  malignant 
pustule  much  more  probable  than  if  no  such  interference  had  been 
made.  Even  so  insignificant  trauma  as  may  be  done  by  hypodermic 
inject  i«  >ns  or  attempting  to  lift  the  eschar  are  interdicted.  Second, 
the  part  affected  must  be  protected  from  all  other  disturbances 
which  may  cause  a  spread  of  the  infection;  hence,  all  manipulation 
bruising,  and  unnecessary  movement,  active  or  passive,  of  the 
part  is  proscribed,  and  efficient  immobilization  is  done  by  the 
application  of  splints  and  dressings.  The  part  should  then  be 
placed  in  the  elevated  position.  Antiseptic  dressings  may  be 
employed.  I >ut  they  are  probably  of  no  value  except  to  prevent 
secondary  infection.  Such  dressings  should  either  be  applied  and 
kept  moist  or  used  in  the  form  of  a  salve,  which  prevents  sticking 
of  the  dressings.  The  important  points  to  remember  are  rest  and 
absolute  freedom  from  the  slightest  pressure  or  manipulation. 

Serum  Treatment. — In  addition  to  it-  immunizing  property  the 
anti-anthrax  serum  has  proved  to  be  of  great  benefit  in  the  treat- 
ment of  anthrax  in  man.  It  should  be  used  in  all  cases,  whether 
external  or  internal,  and  should  begin  with  large  doses.  The 
mortality  is  very  materially  reduced  by  its  employment. 


CHAPTER  XIV 
GLANDERS,  FARCY,  EQUINIA,  MALLEUS 

THIS  is  an  infectious  disease  produced  by  Bacillus  mallei,  and 
characterized  by  the  formation  of  pustules,  abscesses,  and  ulcers. 

Etiology. — The  cause  of  glanders,  the  Bacillus  mallei,  is  trans- 
mitted to  man  usually  from  the  horse,  ass,  or  occasionally  other 
animals,  and  thus  the  disease  occurs  most  frequently  hi  those  who 
care  for  or  use  these  animals.  The  bacillus  gains  access  to  the 
tissues  through  wounds,  ulcers,  and  rhagades;  their  ability  to  pro- 
duce the  disease  consequent  upon  rubbing  the  bacteria  into  the 
skin  has  been  demonstrated  hi  experiments  on  animals.  They  may 
be  recovered  from  the  lesions,  their  discharges,  or  the  blood. 

Pathology. — The  changes  produced  by  the  disease  are  not  char- 
acteristic, and  are  those  of  a  violent  infection,  so  far  as  the  viscera 
are  concerned;  the  local  changes  conform  to  the  type  of  lesion  pro- 
duced— inflammatory,  pustular,  or  ulcerative — as  the  case  may  be, 
with  now  and  then  the  appearance  of  gangrene.  These  changes  are 
seen  with  greater  frequency  in  the  mucous  membrane  of  the  air- 
passages  and  in  the  lungs,  or  in  the  skin  and  subcutaneous  tissue, 
although  suppurative  and  inflammatory  changes  are  often  seen 
widely  distributed  throughout  the  body,  especially  in  the  muscles 
and  joints,  while  any  mucous  surface  may  be  attacked. 

Symptoms. — There  are  two  distinct  types,  dependent  upon  the 
anatomic  site  of  infection  and  upon  the  spread  from  the  primary 
focus.  Farcy  is  the  type  which  affects  the  skin  and  subcutaneous 
tissues,  the  external  type.  Glanders,  the  internal  type,  affects  the 
mucous  membrane  of  the  nose,  air-passages,  and  lungs.  Either  may 
be  accompanied  by  the  other  or  followed  by  it.  Either  may  be 
acute  or  chronic.  The  acute  forms  of  both  farcy  and  glanders 
never  become  chronic,  but  the  chronic  form  of  either  may  at  any 
time  become  acute. 

The  constitutional  symptoms  of  the  disease  are  dependent  upon 
the  absorption  of  toxins  from  the  infected  tissues,  and  not  upon  the 
presence  of  one  type  or  another.  Hence,  a  description  of  the  gen- 
eral symptomatology  may  be  given  at  once.  The  period  of  incu- 
bation is  from  three  to  five  days.  The  local  lesions  may  not  show 
up  until  after  the  general  symptoms  appear,  although  the  reverse  is 
the  rule.  The  patient  may  have  a  chill  or  chilliness,  a  rise  of 
temperature  which  may  be  moderate  or  high  at  the  beginning, 

262 


GLANDERS,    FARCY,    EQUINIA,    MALLEUS  263 

headache,  loss  of  appetite,  weakness  or  prostration,  and  severe 
pains  about  the  body,  especially  in  the  muscles,  bones,  and  joints. 
These  pains  continue  throughout  the  course  of  the  disease.  The 
pulse  is  quickened  and  becomes  weak,  and  as  the  disease  advances 
becomes  rapid  and  perhaps  irregular.  Emaciation  comes  on  rapidy 
in  the  acute  cases;  less  rapidly,  but  no  less  surely,  in  the  chronic. 
Nausea  and  vomiting  may  be  present,  and  diarrhea  is  frequently 
seen,  the  stools  being  fetid.  The  mind  may  remain  clear  for  an 
indefinite  period,  dependent  upon  the  type  of  the  disease;  but,  when 
the  intoxication  is  intense  and  when  exhaustion  is  marked,  delirium 
and  coma  ensue,  and  a  typhoid  condition  often  develops.  Death 
i-  often  preceded  by  convulsions. 

The  urine  contains  albumin  and  possibly  blood. 

The  temperature  may  be  slight,  but  rises  as  the  disease  ad- 
vances, reaching  the  highest  point,  105°  F.,  during  the  later  stage 
of  the  acute  types.  The  temperature  shows  distinct  morning 
remissions. 

Farcy. — Acute  farcy  appears  as  a  result  of  cutaneous  infection, 
although  the  atrium  may  have  been  so  insignificant  as  to  escape 
di.-< -overy.  The  beginning  is  manifested  by  the  appearance  of  an 
unhealthy  ulcer,  which  enlarges  and  discharges  a  bloody,  serous 
fluid.  The  part  becomes  inflamed,  swollen,  and  edematous,  as  if 
an  erysipelas  were  present,  and  the  lymphatics  become  enlarged. 
In  about  one  week  from  the  beginning  of  symptoms  nodules  appear 
in  the  muscles,  and,  in  fact,  widely  distributed  throughout  the  body; 
these  appear  as  hard  lumps;  the  skin  over  them  becomes  reddened 
and  cyanotic,  and  after  a  tune  they  rupture,  discharging  a  bloody, 
gluey  fluid,  which,  as  a  rule,  does  not  resemble  pus.  In  the  skin 
over  the  abscesses  blebs  may  form,  and  the  whole  inflamed  mass 
may  become  necrotic  and  fall  away.  The  ruptured  abscesses  are 
not  deposed  to  heal,  but  remain  as  sluggish  ulcers  or  sinuses,  which 
continue  to  discharge  their  characteristic  germ-laden  secretion. 
The  inflammation  may  also  occur  hi  the  connective  tissue  and 
ap]  >» -ir  as  a  phlegmonous  process.  The  joints  become  inflamed  and 
swollen  and  suppurate.  The  constitutional  symptoms  grow  worse 
as  the  local  processes  increase  in  number,  and  the  patient  rapidly 
\  >er<  )rnes  exhausted.  During  the  course  of  the  disease,  from  twenty 
to  thirty  days  from  the  lie^imiing,  the  body  is  covered  more  or  less 
completely,  particularly  on  the  face  and  the  extremities,  with  a 
pu-tular  eruption,  which  may  be  discrete  or  confluent,  and  closely 
re-i •mbles  the  pustular  eruption  of  small-pox,  except  for  the  manner 
of  distribution  and  the  failure  of  the  pustules  to  umbilicate. 

At  any  point  in  the  course  of  acute  farcy  involvement  of  the 
mucous  membranes  of  the  air-p  nd  of  the  lungs  (glanders) 

may  -upervene.  increa.-e  the  MitTerinji,  and  hasten  the  end,  which, 


264  PRINCIPLES   OF   SURGERY 

without  such  complication,  comes  about  six  or  eight  weeks  from  the 
beginning. 

Chronic  farcy  may  begin  more  insidiously  and  slowly,  and  can 
often  not  be  recognized  until  the  disease  is  well  developed;  or  it 
may  begin  with  violent  acute  symptoms,  which  continue  for  a  few 
days  and  gradually  subside.  In  still  other  cases  it  begins  with  local 
evidence  of  wound  infection,  inflammation  associated  with  involve- 
ment of  the  lymph-channels,  and  enlargement  of  the  lymph-nodes. 
The  constitutional  symptoms  are  less  intense  and  less  rapid  in  their 
evolution,  and  in  those  cases  where  they  precede  the  local  manifes- 
tations may  lead  to  various  futile  surmises  as  to  their  cause  and 
fruitless  efforts  at  relief.  After  a  month  or  two  (about  the  time 
death  comes  from  acute  farcy)  the  nodules  and  abscesses  appear, 
but  they  are  less  active  and  less  disposed  to  involve  the  adjacent 
tissues  hi  the  inflammatory  process.  These  nodules  give  rise  to 
little  pain.  Their  behavior  is  the  same  as  that  of  the  abscesses  of 
acute  farcy,  but  they  are  very  slow  to  rupture;  remaining  for 
months,  they  finally  rupture  and  leave  sinuses  and  ulcers,  which,  as 
a  rule,  persist,  although  exceptions  are  found  in  which  healing  is 
prompt  and  complete.  The  phlegmonous  type  of  abscess  ruptures 
earlier.  These  patients  may  seem  to  improve,  and  remain  appar- 
ently free  from  disease  for  some  time,  and  then  another  group  of 
nodules  form,  and  so  on  hi  succession  indefinitely,  with  gradual 
loss  of  vitality  and  flesh.  As  the  disease  advances  the  former 
tendency  for  some  of  the  ulcers  to  heal  diminishes,  and  practically 
all  ruptured  abscesses  remain  as  open  sores. 

The  constitutional  symptoms  gradually  assume  the  character- 
istic group  already  mentioned;  the  prostration  increases,  and  the 
appearance  becomes  like  that  of  advanced  pulmonary  tuberculosis, 
with  chills  and  night-sweats. 

Glanders. — The  infection  begins  in  the  nose,  and  the  same 
inflammatory,  ulcerative,  and  suppurative  lesions  characterizing 
the  disease  elsewhere  on  the  body  are  found  in  the  nose.  Pustules 
and  abscesses  are  seen  on  the  mucous  membrane,  and,  when  the 
soft  tissues  are  destroyed,  leave  the  bone  or  cartilage  denuded  or 
even  perforated.  These  processes  extend  into  the  nose,  pharynx, 
fauces,  larynx  and  trachea,  and  into  the  accessory  sinuses  of  the 
nose.  There  is  an  abundant  discharge  from  the  nostrils,  of  a 
mucous  or  mucopurulent,  often  bloody,  fluid,  which  is  tenacious  and 
highly  infectious. 

The  face,  feet,  and  hands  are  swollen  and  indurated,  and,  after 
a  few  days,  appear  inflamed.  The  lymphatic  involvement  is 
marked.  The  lymph-channels  are  tender  and  so  swollen  that  they 
are  palpable.  The  pustular  eruption,  as  described  under  acute 
farcy,  then  appears  over  the  swollen  and  inflamed  parts.  Blebs, 


GLANDERS,    FARCY,    EQUINIA,    MALLEUS  265 

too,  may  form.  The  site  of  these  pustules  and  blebs  may  become 
gangrenous,  and,  when  the  dead  tissue  separates,  a  discharge  of  the 
so-called  pus  occurs  and  the  underlying  anatomic  structures  are 
It -ft  exposed. 

The  constitutional  symptoms  are  present,  and  grow  worse 
with  the  advance  of  the  disease. 

The  lungs  become  involved,  in  the  form  of  a  pneumonia,  the 
patient  develops  a  cough,  which  may  be  severe,  and  as  the  alveoli 
are  occupied  more  and  more  the  patient  becomes  dyspneic. 

The  pains  in  the  bones  and  joints,  and  the  widely  distributed 
nodules  with  the  usual  behavior,  appear  just  as  in  the  other  type. 
This  is  the  most  rapid  form  of  the  disease,  and  terminates  hi 
death  in  a  few  weeks  at  most. 

Chronic  glanders  is  similar  to  the  acute  type,  but  different  in 
intensity  and  rapidity.  It  usually  comes  as  a  sequence  of  chronic 
furry.  The  nasal  lesions  are  present,  but  are  often  so  insignificant 
as  to  cause  little  discomfort  and  to  escape  the  closest  examination. 
There  may  be  stuffiness  of  the  nose,  and  more  or  less  discomfort  in 
t  he  region  of  the  nose  and  the  frontal  sinuses.  The  discharges  may 
be  abundant,  as  in  the  acute  type,  or  almost  entirely  wanting. 
The  constitutional  symptoms  are  identical  in  character  with  the 
iption  already  given,  but  less  marked.  Cough  is  frequent 
and  harassing.  The  ulcers  are  found  in  the  same  locations  as  hi 
the  acute  type.  The  voice  is  unnatural.  The  lungs  become 
involved,  as  is  evidenced  by  the  increased  cough,  expectoration,  and 
dyspnea.  If  the  pharynx  is  affected  swallowing  is  painful. 

Diagnosis. — Glanders  and  farcy  doubtless  often  go  unrecog- 
i/ed,  owing  to  the  obscurity  of  the  symptoms  or  to  the  intrinsic 
iculty  many  cases  present  to  the  diagnostician.     The  disease, 
/hen  well  developed  and  acute,  presents  great  similarity  to  pyemia, 
for  which  it  is  probably  frequently  mistaken.     The  history  of  the 
Kitient's  association  with  animals,  particularly  horses,  is  always 
iportant.     The  injection  of  mallein  gives  a  reaction  similar  to 
iat   produced  by  hypodermic  employment  of  old  tuberculin  in 
iberculosis.     It  also  produces  a  local  reaction.     The  reaction 
establishes  the  presence  of  Bacillus  mallei  as  the  etiologic  agent. 
'he  mallein  test  has  proved  its  value  beyond  question  in  the  lower 
ials,  but  IN  reliability  for  diagnosis  hi  human  infection  remains 
\judice.    The  most  reliable  laboratory  test  is  the  injection  of  the 
d  discharge  into  the  peritoneal  cavity  of  male  guinea-pigs, 
testicles  in  these  animals  become  swollen  and  inflamed,  and 
ippurate  in  two  or  three  days,  as  a  rule,  if  the  bacillus  is  present, 
id  pnre  cultures  may  be  obtained  from  these  organs.     Failure 
lay  result  from  death  of  the  pigs  from  mixed  infection. 
The  period  of  incubation  is  longer,  three  to  five  days,  in  glanders 


266  PRINCIPLES   OF   SURGERY 

than  in  ordinary  pyogenic  infections.  Microscopic  examination 
may  be  necessary  to  clear  up  the  diagnosis.  When  the  atrium  of 
infection  cannot  be  discovered  the  disease  may  be  confused  with 
typhoid  fever.  However,  the  Widal  reaction  or  cultures  hi  ox-gall 
media  will  remove  this  source  of  confusion. 

In  the  chronic  types  the  appearance  of  the  ulcers  which  cica- 
trize on  one  side  and  spread  on  the  other  (resembling  the  kidney- 
shaped  ulcerating  gumma),  the  denudation  of  bone,  cartilage, 
tendons,  etc.,  may  lead  to  a  suspicion  of  syphilis.  Wasserman's 
reaction,  the  therapeutic  test,  and  the  history,  together  with  col- 
lateral symptoms,  should  lead  to  a  correct  decision. 

Small-pox  may  be  suspected,  yet  the  course  of  the  two  diseases 
is  so  different  that  discrimination  should  be  easy.  The  fact  that 
the  pustules  of  small-pox  umbilicate,  while  those  of  glanders  do  not, 
differentiates  them;  the  distribution  of  the  eruption  in  the  two  dis- 
eases further  separates  them. 

Prognosis. — The  acute  forms  of  glanders  and  farcy  almost 
always  terminate  fatally.  Death  comes  in  acute  glanders  in  one 
to  six  weeks,  and  ha  acute  farcy  after  a  slightly  longer  time.  The 
chronic  forms  may  continue  indefinitely,  and  produce  death  by 
suddenly  becoming  acute  or  by  exhaustion.  Some  50  per  cent,  of 
the  chronic  cases  recover,  and  this  is  more  probable  in  farcy  than 
hi  glanders. 

Treatment. — The  same  rules  of  prophylaxis  are  to  be  followed 
here  as  hi  other  severe  infections.  Everything  that  could  possibly 
have  been  contaminated  by  the  patient  or  the  animal  should  be 
either  destroyed  or  efficiently  sterilized.  The  attendants  must 
guard  themselves  cautiously  against  infection. 

There  is  no  treatment  so  far  that  influences  the  disease  very 
markedly  after  it  has  once  developed.  If  a  wound  is  known  to  be 
contaminated,  immediate  destruction  of  the  wound  surface  by 
actual  cautery  or  escharotics  will  prevent  infection.  After  the 
lapse  of  one  hour  such  procedure  is  of  questionable  value.  Amputa- 
tion, if  done  early,  has  prevented  general  infection  oftener  than  any 
other  plan. 

The  treatment  of  local  lesions,  ulcers,  abscesses,  and  sinuses 
must  be  rigorous.  The  abscesses  are  to  be  opened;  the  abscess 
cavities,  the  ulcers,  and  sinuses  are  then  cleansed,  perhaps  curetted, 
and  cauterized  with  the  actual  cautery,  or  swabbed  out  with  a  posi- 
tive escharotic  or  active  bactericide,  as  Harrington's  solution  or  a 
solution  of  zinc  chlorid.  Lesions  of  the  mucous  membrane  of  the 
air-passages  should  be  cleansed  frequently  by  irrigation  or  by  ap- 
plication of  the  solution  on  stick  sponges,  provided  the  lesions  are 
accessible.  The  drugs  recommended  here  are  boric  acid  or  potas- 
sium permanganate  solutions,  which  may  be  more  efficiently  admin- 


GLANDERS,    FARCY,    EQUINIA,    MALLEUS  267 

after  cleansing  with  peroxid  of  hydrogen.  Subsequently 
an  antiseptic  powder  may  be  insufflated  or  blown  into  the  nostrils. 
The  constitutional  treatment  is  of  little  or  no  curative  value. 
It  is  directed  toward  the  needs  of  the  case  as  they  arise;  tonic, 
stimulant,  and  nutritive  measures  are  employed.  Various  drugs 
have  been  employed,  the  most  favored  among  them  being  benzoate 
of  soda,  sulphur,  and  mercury  by  inunction.  But  these  have  little 
« ttt ct  on  chronic  cases,  probably  none  on  acute.  The  employment 
of  mallein  has  been  ardently  recommended.  It  is  administered 
hypodermically  in  doses  of  50  to  75  c.c.  The  benefit  derived  from 
the  use  of  mallein  is  very  doubtful. 


CHAPTER  XV 
ACTINOMYCOSIS 

ACTINOMYCOSIS  is  a  chronic  disease  produced  by  the  ray- 
fungus,  and  characterized  by  the  formation  of  granulomatous 
masses  which  break  down  and  discharge  pus  from  their  sinuses, 
and  by  the  progressive  spread  of  the  inflammatory  process. 

Etiology. — The  classification  of  the  cause  of  actinomycosis,  the 
ray-fungus,  has  not  been  unanimously  agreed  upon.  In  fact,  there 
are  very  diverse  opinions  as  to  its  proper  botanic  position.  The 
ray-fungus  is  a  small  mass,  or  colony,  the  size  of  which  varies  from 
the  minutest  visible,  or  even  microscopic,  mass  up  to  yV  inch  in 
diameter.  These  masses  are  often  kidney  shaped.  The  mass  con- 
sists of  a  central  mass  of  filaments  known  as  mycelia,  and  an  outer 
mass  of  processes,  which  radiate  in  the  form  of  minute  clubs  from 
the  central  mass.  These  clubs  are  not  constant,  and  appear  only 
in  the  older  colonies ;  they  are  connected  at  their  proximal  ends  with 
the  central  mass,  the  fibers  of  which  extend  into  the  clubs.  The 
central  mass  is  made  up  of  two  distinct  parts,  one  encircling  the 
other.  The  inner  portion  contains  fewer  filaments,  which  have  no 
definite  arrangement,  but  which  extend  through  the  surrounding 
layer  at  a  single  spot,  and  send  their  filaments  out  into  the  sur- 
rounding structures.  The  peripheral  zone  shows  a  more  definite 
arrangement;  the  fibrils  radiating  from  the  surface  of  the  inner 
part  are  germinal  elements  of  the  colony,  and  run  in  waving  lines 
outward.  These  filaments  branch  and  the  terminal  ends  enlarge, 
constituting  what  are  supposed  to  be  spores.  Either  the  spores  or 
the  fragments  of  the  germinal  layer  may  develop  into  new  colonies. 
The  ray-fungus  is  found  in  the  soil  and  on  soil  products,  as  grains 
of  wheat  or  barley,  and  on  grass,  straw,  and  the  beards  of  small 
grain  stalks.  It  usually  affects  the  animals  which  feed  upon  such 
products,  and  is  especially  liable  to  affect  cattle. 

The  ray-fungus  is  readily  stained  by  a  number  of  methods, 
may  be  cultivated  on  any  culture-medium,  although  some  of  them 
grow  it  very  indifferently,  and  may  be  readily  recognized  under  the 
microscope,  or,  if  the  pus  is  examined  soon  after  evacuation,  the 
pale  yellow  colonies  may  be  recognized  by  the  naked  eye.  They 
are  characteristic,  but  their  absence  does  not  warrant  a  negative 
diagnosis. 

There  are  many  varieties  of  ray-fungus,  several  of  which  do  not 
affect  mankind.  The  fungus  is  usually  deposited  in  the  tissues  by 


ACTINOMYCOSI8  269 

hay,  grain,  or  straw,  but  it  is  manifest  that  any  substance  carrying 
it  may  produce  the  disease  by  gaining  entrance  into  the  tissues.  It 
sometimes  originates  hi  carious  teeth.  Because  of  the  natural 
hal>its  of  the  fungus,  one  may  readily  understand  that  animals  are 
most  frequently  affected  in  the  mouth  and  jaws  (lumpy-jaw)  or  in 
the  alimentary  tract.  Man  acquires  the  disease  by  chewing  gram, 
by  picking  the  teeth  with  straws,  or  by  placing  any  contaminated 
substance  in  the  mouth.  Occasionally  wounds  of  the  skin  are 
•ffected. 

Pathology. — When  ray-fungus  gains  a  footing  hi  the  tissues, 
which  it  often  does  with  difficulty,  judging  from  frequent  failures 


Fiuv  H. — Actinomycosis  of  liver.   Note  the  rays  of  the  growth.    (X  about  150.) 

of  experimental  inoculation,  there  appears  a  mass  or  nodule  which 
closely  resembles  the  growth  of  sarcoma.  This  mass  is  made  up 
of  granulation  tissue,  abundantly  supplied  with  lymphoid  and  epi- 
thelioid  colls  and  blood-vessels.  Giant  cells  also  appear  in  the 
mass,  and  may  be  abundant  when  certain  organs,  as  the  liver,  kid- 
neys or  heart,  are  affected.  These  masses  may  reach  the  size  of  an 
orange,  sometimes  they  are  even  larger.  The  colonies  are  usually 
sulphur  yellow.  I  nit  may  be  white,  brown,  or  green.  In  the  midst 
of  the  mass  the  ray-fungus  is  found.  After  the  nodules  develop 
one  of  two  change-  occur.  First,  the  granulation  tissue  may  under- 
go fatty  degeneration,  break  down  into  a  puruloid  fluid,  and  pro- 


270  PRINCIPLES   OF   SURGERY 

duce  abscesses  (actinomycotic  abscesses).  The  pus  cavities  are 
surrounded  by  granulation  tissue  or,  when  the  process  has  con- 
tinued for  a  long  time,  with  new-formed  connective  tissue.  Occa- 
sionally mucoid  degeneration  is  found.  The  pus  of  these  is  glairy 
and  tenacious,  and  contains  the  characteristic  sago-like  masses  or 
colonies  of  ray-fungus  and  the  broken-down  cells  of  the  mass. 
The  second  course  pursued  by  the  nodule  is  that,  instead  of  break- 
ing down,  cicatricial  tissue  forms  throughout,  and,  by  contraction, 
causes  shrinkage  of  the  mass  and  retardation  of  its  activity  or 
sometimes  complete  cure.  Calcification  of  the  colonies  may  take 
place;  if  so,  the  fungi  lose  their  vitality,  and  they  then  settle  to  the 
bottom  of  the  fluid  if  it  is  allowed  to  stand  a  short  while.  When 
rupture  has  taken  place  the  tissues  surrounding  the  nodule  are  in- 
vaded, and  as  spreading  continues  on  the  periphery,  breaking  down 
continues  next  the  abscess  cavity  and  chronic  sinuses  are  main- 
tained, the  nature  and  quantity  of  whose  discharge  is  materially 
influenced  by  the  presence  of  mixed  infection.  The  cicatricial 
tissue,  by  its  contraction,  not  only  causes  disfigurement,  sometimes 
almost  pathognomonic  when  affecting  a  skin  surface,  but  also  seri- 
ous impairment  of  function  in  the  viscera.  Owing  to  this  scar-tis- 
sue the  tract  of  extension  from  the  primary  point  of  infection  to  the 
subsequent  nodule  may  be  discoverable,  and  this,  too,  becomes  a 
valuable  diagnostic  point.  The  skin  surface  over  the  nodules 
remains  unchanged  until  it  is  attacked,  then  it  shows  evidence  of 
inflammatory  changes,  and  is  very  similar  in  appearance  to  the 
skin  covering  a  sarcoma. 

The  usual  method  of  spread  of  actinomycosis  is  by  direct  exten- 
sion. However,  a  general  infection  may  take  place  when  the  ray- 
fungus  extends  into  a  blood-vessel  and  the  enclosed  clot  disinte- 
grates and  enters  the  circulation. 

Symptoms  of  Actinomycosis. — Actinomycosis  is  essentially 
a  chronic  condition,  and  there  are  few  constitutional  symptoms 
except  such  as  grow  necessarily  out  of  a  long-continued  local  inflam- 
mation, namely,  exhaustion  and  emaciation.  These  conditions 
will  not  be  found  marked  in  the  average  case.  In  some  cases  fever 
is  present,  but  it  is  usually  due  to  secondary  pyogenic  infection. 
The  lymph-nodes  are  not  enlarged  in  unmixed  infections.  When  a 
general  metastatic  infection  occurs  the  course  of  the  disease  re- 
sembles septicemia  and  is  fatal.  When  death  comes  it  is  due  either 
to  mixed  infection  or  to  exhaustion  and  amyloid  change  in  import- 
ant organs. 

There  are  four  types  of  actinomycosis  usually  described,  al- 
though it  must  not  be  inferred  that  these  are  the  only  structures 
affected.  The  types  are  actinomycosis  (a)  of  the  jaws  and  mouth, 
(6)  of  the  skin,  (c)  of  the  lungs,  (d)  of  the  alimentary  tract. 


ACTINOMYCOSIS  271 

Actinomycosis  of  the  Jaws  and  Mouth. — This  form  of  the  disease 
is  the  most  frequent,  and  comes,  as  already  shown,  from  the  habit 
of  putting  sticks  and  grain  into  the  mouth,  where  an  atrium  is 
found  in  small  wounds  or  abrasions  of  the  mucous  membrane  and 
in  carious  teeth.  There  may  be  insignificant  infiltration  at  the 
atrium,  but  the  infection  extends  through  the  tissues  and  produces 
tin-  nodules  in  the  jaw,  face,  and  neck,  rarely  in  the  tongue.  An 
indurated  cord  is  found,  but  not  constantly,  leading  from  the 
atrium  in  the  mucous  membrane,  if  infection  occurred  there,  to  the 
nodule.  This  cord  is  not  found  in  other  conditions.  When  the 
nodule  ruptures,  and  surrounding  structures  are  infiltrated  and 
cicatrization  takes  place,  great  disfigurement  occurs.  When  this 
happens  in  the  neck  the  skin  overlying  the  lesion  is  thrown  into 
more  or  less  transverse  folds,  an  appearance  rarely  produced  by 
other  conditions.  The  muscles  of  the  jaw  become  infiltrated  and 
functionless,  and  the  joint  and  surrounding  structures  are  in- 
volved, so  that  the  jaw  becomes  immovable.  The  cranial  cavity 
is  occasionally  invaded,  with  sinister  results.  The  pus  from  ab- 
scesses in  the  lower  part  of  the  neck  may  gravitate  downward 
into  the  chest  cavity  or  even  into  the  abdomen.  The  cervical 
vertebrae  and  cord  may  become  involved. 

Actinomycosis  of  the  Skin. — This  type  of  actinomycosis  usually 
appears  secondary  to  one  of  the  other  forms,  but  is  occasionally 
primary,  gaining  a  footing  in  wounds  involving  the  surface.  It  is 
found  more  frequently  on  the  face  and  neck,  but  may  occur  on  other 
I  Ctrl  -.  The  primary  sore  often  resembles  syphilitic  ulcers  or  lupus, 
and  when  affecting  the  foot  and  extending  into  the  underlying 
bones  it  may  resemble  madura-foot.  Nodules  form  in  the  region 
of  the  primary  lesion,  and  gradually  extend  until  the  process  may 
reach  deeply  into  tissues  and  possibly  surround  the  bone  and  give 
the  impression  that  an  osteomyelitis  is  present.  A  skiagraph 
should  clear  up  the  question.  The  nodules  in  actinomycosis  of  the 
skin  run  the  same  course  as  elsewhere,  suppurating,  softening, 
rupturing,  and  producing  chronic  sinuses  and  ulcers. 

Actinomycosis  of  the  Lungs. — Actinomycosis  of  the  lungs  may 
begin  on  the  mucous  membrane  of  the  lungs  or  as  bronchopneu- 
monia.  Any  part  of  the  lungs  may  be  affected,  but"  the  lesions  are 
mo<t  frequently  found  in  the  lower  lobes.  One  or  both  lungs  may 
be  affected.  The  source  of  infection  is  through  the  mouth  and  nose, 
and  is  often  secondary  to  actinomycosis  of  the  nose.  The  foci 
develop,  and  may  run  either  of  the  usual  courses.  In  case  ab- 
'•s  form  and  rupture  the  discharge  is  coughed  up,  and  contains 
the  characteristic  colonies;  or,  a>  i<  more  common,  the  granulation 
ma— e-;  are  -urrounded  by  dense  connective  tissue,  the  pleura  is 
involved,  and  the  lung  adheres  to  the  chest-wall.  The  stiff,  hard, 


272  PRINCIPLES   OF   SURGERY 

fibrous  mass  may  occupy  practically  the  whole  of  the  lung,  and  the 
mass  be  occupied  by  suppurative  foci  and  fistulse  scattered  through- 
out. There  is  great  tendency  for  the  lesion  to  spread  to  the  en- 
virons of  the  lung.  The  condition  is  difficult  to  differentiate 
from  pulmonary  tuberculosis  for  two  reasons,  namely,  because  the 
signs  and  symptoms  are  similar  and  both  diseases  respond  to  tu- 
berculin tests.  It  is  not  uncommon  to  find  the  process  extending 
from  the  lung  to  the  chest-wall  and  rupturing  on  the  cutaneous  sur- 
face, rarely  through  the  diaphragm  into  the  liver  or  other  ab- 
dominal organs. 

Actinomycosis  of  the  Alimentary  Tract. — Actinomycosis  of  the 
alimentary  tract  may  originate  in  any  portion  of  the  canal  excep- 
tionally; it  occurs  with  far  greatest  frequency  in  the  ileocecal  region; 
therefore  it  may  be  easily  confused  with  appendicitis,  producing 
pain,  tenderness,  and  fever  resembling  closely  the  symptoms  of  the 
latter  disease.  The  course  of  the  disease  is  hi  no  way  different  from 
the  usual,  except  as  determined  by  anatomic  conditions.  Ad- 
hesions, nodules,  suppuration,  rupture  into  the  hollow  viscera  or 
externally  (the  latter  occurs  more  frequently  than  hi  the  pyogenic 
processes),  and  the  establishment  of  fecal  fistulse.  Intraperitoneal 
rupture  produces  peritonitis.  This  type  of  actinomycosis  is  slow 
in  development,  and  may  remain  obscure  for  a  long  time,  or  the 
abdomen  may  likely  be  opened  for  removal  of  the  appendix. 

Diagnosis. — The  similarity  between  actinomycosis  and  sarcoma 
is  very  striking,  and,  up  to  the  time  when  softening,  rupture,  and 
discharge  of  the  characteristic  pus  occurs,  it  may  be  impossible  to 
differentiate  the  two  without  recourse  to  a  microscopic  investiga- 
tion. If  an  atrium  can  be  found  from  which  an  indurated  cord 
leads  to  the  nodules,  sarcoma  can  be  eliminated.  The  presence  of 
nodules  may  lead  to  the  suspicion  of  gummata,  and  the  appearance 
of  chronic  sinuses  and  enlargements  hi  the  region  of  the  bones 
may  confound  this  disease  with  syphilis  or  with  osteomyelitis  from 
other  causes.  Tubercle  and  syphilis  may  both  have  to  be  excluded ; 
the  former  can  be  eliminated  by  inoculation  and  bacteriologic 
investigation,  not  by  tuberculin  reactions;  the  latter  by  Wasser- 
mann's  reaction,  by  definite  history  of  the  disease,  or  by  collateral 
symptoms. 

When  secondary  infections  occur,  the  pyogenic  bacteria  may 
dominate  and  give  evidence  of  a  more  rapid,  more  acute  condition 
than  actinomyces  would  produce.  General  infection  with  ray- 
fungus  resembles  septicemia  or  pyemia. 

Discovery  of  the  ray-fungus  is  conclusive  in  all  cases,  but  it 
must  be  remembered  that  under  certain  circumstances  this  evi- 
dence is  difficult  or  impossible  of  demonstration. 

Prognosis. — Actinomycosis    is    usually    a    chronic    condition, 


ACTINOMYCOSIS  273 

except  the  pyemic  form,  in  which  the  course  runs  more  rapidly  to 
a  fatal  termination.  The  more  superficial  lesions  are  more  favor- 
able than  those  of  the  lungs  and  intestines,  but  recovery  hi  the 
mil*  1  cases  cannot  be  expected  hi  less  than  six  to  ten  months.  When 
thr  rent  nil  nervous  system  or  important  viscera  are  invaded  the 
prognosis  is  hopeless.  A  few  pulmonary  cases  have  been  known 
to  nrover.  The  cause  of  death  is  usually  exhaustion,  emacia- 
tion, and  amyloid  degeneration. 

Treatment. — The  fact  that  actinomycosis  is  a  localized  infec- 
tion in  the  majority  of  instances  renders  its  treatment  to  a  large 
degree  surgical,  provided  the  foci  are  accessible  and  can  be  removed 
without  too  great  sacrifice  of  tissues.  When  the  foci  are  in  the 
hums  and  hi  the  intestines,  the  probability  of  benefit  and  the  advis- 
ability of  attempting  surgical  relief  are  much  reduced,  and,  if  the 
infection  has  already  gained  a  wide  hold  on  the  structures,  such 
efforts  are  rendered  nugatory.  After  removal  of  the  diseased  tis- 
sue- the  wound  is  to  be  thoroughly  disinfected  with  strong  antisep- 
tic-, bichlorid,  carbolic  acid,  or  Harrington's  solution.  The  ab- 
scesses may  be  incised,  and  all  the  granulation  tissue  cleaned  out 
with  a  curet  and  the  cavity  packed  with  iodoform  gauze,  with  or 
without  the  use  of  antiseptic  irrigation;  mixed  infection  must  be 
prevented  if  possible.  Bevan  recommends  copper  sulphate  given 
internally  in  pills,  aa  gr.  J  t.  i.  d.,  and  irrigation  of  the  sinuses  with 
a  1  per  cent,  aqueous  solution  of  the  same  drug. 

Aside  from  the  internal  administration  of  sulphate  of  copper, 
mentioned  above,  the  general  treatment,  tonics,  stimulants,  and 
diet  must  be  administered  pro  re  nata.  One  drug  stands  out 
pre-eminently  as  the  most  satisfactory  therapy,  namely,  potassium 
uxlitl. 

18 


CHAPTER  XVI 
TUBERCULOSIS 

TUBERCULOSIS  is  any  lesion  produced  by  the  tubercle  bacillus 
of  Koch.  The  disease  may  affect  any  tissue  in  the  body  at  any 
tune  of  life,  although  the  various  types  of  the  disease  are  more  or 
less  prevalent  at  rather  indefinitely  marked  ages.  The  tissues 
affected  and  the  complications  arising  determine  more  whether 
the  condition  is  to  be  classified  as  a  medical  or  a  surgical  one  than 
the  nature  of  the  lesion,  for  fundamentally  the  lesions  are  identical. 
Tuberculosis  is  one  of  the  very  common  diseases,  so  usual,  indeed, 
that  physicians  accept  many  other  conditions  unquestionably  as 
tubercular,  without  having  gone  to  the  pains  of  making  an  accurate 
diagnosis. 

The  question  often  arises  as  to  whether  a  case  of  tuberculosis 
should  be  considered  a  surgical  or  a  medical  case.  Many  cases  of 
tuberculosis  that  have  been  unquestionably  surgical  until  recently, 
have,  by  recent  advances  hi  treatment,  been  handed  back  to  the  in- 
ternist, who  is  able  now  to  cope  with  them  much  more  satisfactorily 
than  the  surgeon  can.  To-day  there  is  scarcely  a  single  type  of 
uncomplicated  tuberculosis  that  may  be  said  to  be  always  a  surgical 
condition — i.  e.,  curable  only  by  operation.  It  may  be  safely 
stated  that  every  case  of  tuberculosis  is  a  medical  lesion  prior  to, 
during,  and  subsequent  to  surgical  treatment,  if  the  latter  is  at  all 
necessary;  that  comparatively  few  cases  are  or  should  be  surgical, 
and  these  are  largely  such  because  of  failure  of  the  patients  to  seek 
competent  medical  advice,  or  because  of  failure  of  the  physician  to 
recognize  the  true  nature  of  the  condition  and  to  institute  proper 
treatment.  The  field  of  treatment  of  tuberculosis  by  surgery  is 
growing  constantly  more  restricted,  and  the  estimate  of  the  value 
of  necessary  surgical  treatment  is  assuming  a  much  less  important 
role  than  it  once  held.  Hence,  in  giving  the  tubercular  condition 
in  detail  in  the  following  pages,  while  I  have  yielded  to  the  older 
conceptions  of  surgical  tuberculosis,  I  hope  I  have  not  failed  to 
make  plain  when  they  are  to  be  accepted  as  surgical  lesions,  and 
why  they  are  not  so  frequently  considered  amenable  only  to  opera- 
tion. 

Sources  of  Infection. — It  is  superfluous  to  discuss  at  length  the 
sources  of  infection.  The  usual  methods  of  contamination  come 
from  the  nature  of  our  food  and  social  customs.  Most  cases  of 

274 


TUBERCULOSIS  275 

tuberculosis  are  traceable  either  to  dairy  supplies,  meat  supplies, 
or  to  individuals  who  have  the  disease.  It  is  true  that  most  chil- 
dren affected  with  the  disease  in  any  form  are  infected  from  milk 
(the  din-use  is  quite  prevalent  among  dairy  cattle,  and  they  often 
show  no  evidence  of  it  in  a  clinical  way)  or  from  a  tuberculous  in- 
habitant of  the  same  house,  frequently  a  parent  or  a  nurse.  The 
bacteria  are,  in  the  above  manner,  delivered  to  the  individual  daily, 
hourly,  and  it  is  incredible  that  one  should  escape  infection  when 
forced  to  live  continuously  under  such  an  influence.  Tuberculous 
patients  often  cough  in  the  face  of  their  friends  or  the  physician,  or 
attempt  to  come  very  near  and  speak  directly  at  your  nostrils 
during  conversation,  or  are  guilty  of  indiscriminate  expectoration. 
It  is  superfluous,  too,  to  say  that  the  dust  from  houses  occupied 
by  people  who  have  pulmonary  tuberculosis  or  a  discharging  sinus 
or  tuberculosis  of  the  rectum,  bladder,  or  kidneys  is  very  likely  to 
be  polluted  by  the  specific  bacteria,  and  that  food  prepared  by  such, 
one  type  as  well  as  another,  is  entirely  untrustworthy,  especially 
uncooked  food  or  that  handled  by  such  an  individual  subsequent 
to  cooking.  The  importance  of  association  with  tubercular  patients 
is  so  great  that  the  great  insurance  companies  now  refuse  to  insure 
one  who  has  lived  in  the  house  with  a  case  of  tuberculosis  until  after 
the  expiration  of  five  years. 

Atria  of  Infection. — Tuberculosis  gains  entrance  to  the  tissues 
chiefly  through  the  alimentary  and  the  respiratory  tracts,  occasion- 
ally by  direct  infection  of  wounds.  The  bacteria  are  swallowed 
with  food  or  drink,  and  pass  into  the  lacteals  with  the  food,  are 
ul>M>rbed  from  the  intestine,  and  pass  thus  to  the  lymph-nodes, 
where  they  gain  a  footing,  or  into  the  general  circulation  with  the 
chyle,  whence  they  are  lodged  at  various  points  in  the  body;  they 
find  a  more  likely  field  for  development  in  tissues  that  have  recently 
been  subjected  to  trauma  or  disease;  hence,  the  frequency  with 
which  surgical  tuberculosis  is  observed  to  originate  soon  after  an 
injury,  even  though  slight,  or  after  an  inflammation.  They  may 
find  lodgment  on  the  mucosa  of  the  gut,  and  by  direct  extension 
rough  its  wall  attack  the  peritoneum.  The  most  frequent 
jurce  of  tubercular  peritonitis,  especially  hi  the  male,  is  such  an 
Feet  ion  of  the  vermiform  appendix.  On  the  other  hand,  it  is 
robably  true  that  many  more  cases  of  tuberculous  infection  arise 
nigh  the  tonsils  than  by  direct  attack  of  the  lungs.  It  is  known 
»at  a  great  majority  of  " hyper t rophied"  tonsils  and  adenoids 
>ntain  tubercle  bacilli  '.-ome  authorities  claim  as  high  jus  75  per 
•nt.  ,  and  that  from  such  tonsils  the  lymph-nodes  of  the  neck  are 
•xt  involved,  and  subsequently  various  near  and  remote  organs. 
rious  teeth,  too.  may  produce  a  -imilar  course.  The  genital  and 
rinary  organs  are  likewise  rather  frequently  affected  with  primary 


276  PRINCIPLES   OF   SURGERY 

tuberculosis;  but  it  is  probable  that  the  bacteria  are  usually  brought 
through  the  circulation  in  most  cases  and  lodged  upon  structures 
already  crippled  by  disease,  most  frequently  gonorrhea.  The  tubes 
in  women  and  the  testicles  and  seminal  vesicles  in  men  are  the  most 
frequent  sites  of  infection.  In  attempting  to  eliminate  tubercle 
bacilli  from  the  blood  the  kidneys  themselves  become  infected,  and 
from  them  the  bacilli  are  transmitted  to  the  bladder,  which  usually 
shows  distinct  evidence  of  involvement;  and  this,  in  cases  of  renal 
tuberculosis,  is  worse  around  the  ureter  leading  from  the  diseased 
kidney  (both  kidneys  may  be  affected  synchronously  or  at  different 
times) ,  and  may  be  confined  to  the  vicinity  or  be  more  or  less  widely 
distributed  over  the  mucosa.  Or  the  kidneys  may  succeed  hi 
throwing  off  the  bacilli,  and  a  primary  infection  may  occur  then  in 
the  bladder. 

Pathology  (Kaufmann). — The  fundamental  and  essential 
changes  produced  by  tuberculosis  are  found  in  the  tubercle.  A 
tubercle  is  a  mass  of  new-formed  cells,  epithelioid  and  giant,  fine 
connective-tissue  fibrils,  occasional  lymphocytes,  and  tubercle 
bacilli.  It  is  of  a  grayish  color  and  somewhat  translucent.  The 
tubercle  is  surrounded  also  by  lymphocytes  and  occasional  poly- 
morphonuclear  leukocytes.  The  epithelioid  and  fibroblastic  cells 
and  the  giant  cells  are  accepted  as  typical  structures  which  char- 
acterize the  tubercle.  However,  in  occasional  instances,  tubercles 
show  few  or  no  cells  of  these  types,  but  are  made  up  of  lymphocytes, 
and  are  spoken  of  as  lymphoid  or  small-celled  tubercles.  The 
derivation  of  tubercle  from  normal  tissues  occurs  in  the  following 
manner :  The  bacilli  are  deposited  in  greater  or  smaller  numbers  and 
liberate  their  poisons,  which  serve  as  an  irritant  and  cause  prolifera- 
tive  inflammatory  reaction.  The  fixed  connective-tissue  cells  and 
the  epithelial  (endothelial)  cells  (if  such  be  present)  are  incited  to 
increased  activity  and  multiply  at  an  abnormal  rate;  a  mass  of 
cells  the  size,  say,  of  a  millet  seed  is  formed,  which  is  devoid  of 
blood-vessels.  The  cells  are  larger  than  normal.  The  giant  cells 
are  large  and  multinucleated,  and  the  nuclei  are  situated  at  the 
periphery  only,  the  result  of  an  ineffectual  attempt  at  multiplication, 
the  nuclei  dividing  and  the  protoplasm  failing  to  divide  on  account 
of  death  of  a  great  part  of  it;  or  they  are  due  to  fusion  of  the 
endothelial  cells.  The  connective-tissue  fibrils  of  the  tubercle 
are  partly  the  remains  of  broken-down  normal  connective  tissue, 
partly  new-formed  tissue,  and  partly  the  processes  of  cells  consti- 
tuting the  tubercle.  The  fewer  and  less  virulent  the  bacilli  the 
sooner  epithelioid  and  fibroblastic  cells  appear.  The  lymphocytes, 
occasional  polymorphonuclear  leukocytes,  and  fibrin  come  from  the 
surrounding  blood-vessels  as  a'  result  of  the  inflammation.  After 
the  development  of  the  tubercle  it  begins  to  undergo  degeneration 


TUBERCULOSIS 


277 


into  a  finely  granular,  somewhat  hyaline,  caseous  substance; 
this  process  commences  in  the  center  and  extends  toward  the 
periphery. 

Tubercle  bacilli  are  found  in  varying  numbers  in  the  tubercle, 
living  cither  between  the  cells  or  within  the  substance  of  the  giant 
and  epithelioid  cells.  In  caseating  portions  the  bacilli  gradually 
disappear.  Sometimes  they  are  seen  in  heaps  in  the  midst  of 
caseous  material. 

The  course  of  tubercles  is  variable.  In  the  majority  the  tend- 
ency toward  caseation  is  very  apparent,  but  by  no  means  all  of 
tin  in  follow  this  course.  In  one  instance  a  bit  of  fibrous  tissue 


Fig.  44.— Fibroid  phthisis.     Tubercles  in  the  lung  surrounded  by  fibrous  tis- 
sue.    Note  numerous  giant  cells.     (X  about  -100.) 

forms  in  the  periphery  of  the  tubercle,  and  encapsulates  the  central 
•  •abating  portion  and  effects  a  cure,  symptomatically  at  least. 
However,  t  he  I  ..-irilli  enclosed  in  this  capsule  retain  their  vitality  and 
are  ready  to  return  to  activity  when  occasion  is  offered,  as  is  shown 

by  the  readiness  with  which  certain  old  healed  tuberrulous  proc- 
i-erurwhen  the  ti— in- containing  their  remain-  have  been  sub- 
j, Tt,-d  to  tranmat'iHii.  In-te.-id  of  the  above  course,  the  develop- 
ment of  fihrou<  tis>ne  may  take  place  throughout  the  tubercle,  be- 
fore caseation  has  l.egun.  and  tlie  whole  ma—  i-  ••onverted  into  a 
cicatrix,  riTeeting  a  cure.  Sometimes  hyaline  degeneration,  both 


278 


PRINCIPLES   OF   SURGERY 


of  the  connective  and  the  cellular  tissue  of  the  tubercle,  takes  place. 
In  rare  cases  the  caseated  tubercular  masses  have  lime  salts  depos- 
ited in  them  in  varying  quantities,  so  that  the  deposits  appear  in  the 
form  of  small  particles  or  occupy  the  whole  affected  structure. 
This  is  especially  true  of  lymph-nodes.  This  process  is  not  peculiar 
to  tuberculous  nodes,  it  sometimes  occurs  also  in  cancerous  lymph- 
nodes. 

When  the  behavior  of  the  single  tubercle  is  understood  the 
general  action  of  large  areas  of  tuberculosis  in  the  tissues  becomes 
a  simple  process.  If  the  tubercles  form  hi  large  numbers  and  run 
their  usual  course,  a  considerable  portion  of  tissue  is  destroyed  and 


Giant 


as 


s&g 

^fOgca 

JLi  -  *  1-w. 


*J3S? 


&££•< 


''••^  ',  "'^  *  <C  •^t'J^-v.Ji    >/V  "iV""    tri^SfliSy  •*'•    '    •'     ^  *-"%'**  *_- •  '•'•?•  *  »V* 

^$f^v         Sa^i^7 

%^-^:5  ^^^^^^S^^ ' 
'-'.'x./<i^f>"^5.. 

^^MS^?^ 


;.> 

Fig.  45. — Tubercles.    Section  of  liver  showing  fatty  degeneration.    CX  about 

100.) 

general  and  local  symptoms  compatible  with  such  loss  develop, 
due  to  the  replacement  of  vital  tissue  by  a  devitalized  and  function- 
less  mass  and  the  absorption  of  large  quantities  of  poison  from  the 
bacteria.  If  the  process  is  on  a  surface,  it  is  manifest  that  an  ulcer 
forms  when  the  breaking  down  occurs;  if  it  involves  an  organ  that 
may  throw  off  the  debris,  such  as  the  lung,  the  appearance  of  solidi- 
fication followed  by  cavity  formation,  hemorrhage,  and  secondary 
infection  is  a  necessary  consequence,  provided  the  usual  changes 
occur.  If  the  process  is  in  closed  spaces,  such  as  bones,  lymph- 
nodes,  and  the  normal  body  cavities,  then  when  caseation  occurs  the 
debris  must  accumulate,  and,  with  the  greater  or  smaller  quantity 
of  exudate  plus  the  wreckage  of  destroyed  tissues  and  the  scattered 


TUBERCULOSIS 


279 


bacilli,  make  up  the  puruloid  material  known  as  tubercular  pus.  In 
serous  cavities  tubercular  infection  may  produce  either  a  fibrous, 
serous,  or  puruloid  exudate,  dependent  on  the  changes  effected  in  the 
course  of  the  evolution  of  the  tubercles. 

Tuberculous  Abscess. — Inasmuch  as  various  tubercular  proc- 
esses result  in  the  development  of  the  so-called  tubercular  or  cold 
abscess,  it  is  necessary  to  discuss  this  condition.  Any  accumula- 
tion of  tubercular  pus  in  an  abnormal  cavity  is  called  a  tubercular 
abscess.  It  is  the  common  type  of  cold  abscess,  which  simply  in- 
dicates that  no  acute  inflam- 
mation is  present;  it  may  have 
been  always  absent,  or  it  may 
have  been  present  and  sub- 
sided. The  accumulation  of 
the  fluid  resulting  from  casea- 
tion  and  emulsion  of  the  tuber- 
cular  products  either  remains 
at  the  site  of  its  formation,  as 
is  usually  the  case  in  acute 
abx-esses,  or  ex-apes  from  this 
point  and  wanders  along  until 
anatomic  or  pathologic  limits 
arc  reached,  and  a  wandering 
or  gravitative  abscess  is  es- 
tablished, the  most  interesting 
form  of  which  is  the  psoas 
al>x-es.s.  Tubercular  abscesses 
are  occasionally  subacute  and 
rarely  acute,  or  nearly  so. 

The  most  frequent  sources 
of  tubercular  abscesses  are  in- 
fection of  the  lymph-nodes 
and  the  osseous  system. 
Serous  membranes,  too,  are 
frequent  sources  of  tubercular 
pus,  which  accumulates  in  the  form  of  an  empyema.  The  deep 
fax-he  occasionally  become  infected  with  tubercle  bacilli  and  cause 
tubercular  abscesses. 

The  development  of  a  tuberculous  abscess  may  be  rapid  or  slow, 
uxially  the  latter.  There  is  no  history  of  an  acute  inflammatory 
process,  but  one  of  a  tubercular  infection,  which  is  frequently  so 
obscure  as  to  fail  of  recognition  until  the  abscess  forms,  or  so  insig- 
nificant as  to  escape  the  attention  of  even  the  patient.  Pain,  so 
prominent  in  acute  suppurative  processes,  is  wanting  in  most 
tubercular  abscesses,  except  where  the  accumulation  is  great  and 


Fig.  46. — Tuberculous  abscess  of  thigh. 


280  PRINCIPLES   OF   SURGERY 

discomfort  is  caused  by  the  tension  or  dragging  weight  in  large 
abscesses.  Tenderness  likewise  is  less  marked.  Discoloration  over 
the  surface  of  superficial  tubercular  abscesses  may  be  present,  more 
probably  in  the  quickly  forming  ones,  or,  as  is  usual,  it  may  be 
entirely  wanting.  When  present  it  is  confined  to  the  surface  over 
the  abscess.  Edema  is  absent.  The  abscess  is,  as  a  rule,  not  sur- 
rounded by  an  indurated  zone  of  tissue,  but  is  soft  over  the  whole 
affected  area  alike.  Pointing  does  not  usually  take  place,  but  if 
the  tension  is  great  or  if  the  abscess  continues  for  a  long  time,  point- 
ing and  even  rupture  may  occur.  The  superficial  contour  of  tuber- 
cular abscess  is,  as  a  rule,  different  from  that  of  acute  abscess;  the 
latter  usually  is  a  more  or  less  flattened  elevation,  with  a  higher, 
sharper  apex  at  the  place  of  pointing;  the  former,  as  a  rule,  tends 
more  toward  a  spheric  contour.  Fluctuation  is,  of  course,  present, 
but  the  pus  cannot  be  always  so  easily  aspirated  as  in  acute  abscess, 


Fig.  47. — Tubercular  (cold)  abscess  of  right  thigh. 

owing  to  the  frequent  presence  of  caseous  lumps  in  tubercular  pus. 
In  acute  abscess  it  is  the  rule  that  at  one  point  the  pus  is  consider- 
ably closer  to  the  surface  than  elsewhere.  Usually  a  tubercular 
abscess  gives  the  impression  to  the  palpating  finger  that  the  dis- 
tance from  surface  to  pus  is  uniform  or  nearly  so. 

Tubercular  Lymph-nodes. — The  usual  avenues  of  infection  of 
the  lymph-nodes  by  tubercle  bacilli  is  through  the  lymph-channels, 
which  conduct  the  bacteria  either  from  the  atrium  of  infection  or 
from  an  already  established  tubercular  lesion.  They  are  occasion- 
ally infected  through  the  circulating  blood.  When  a  lymph-node 
infection  occurs,  the  process  may  remain  confined  to  the  node  or 
group  of  nodes  attacked  or  spread  indefinitely  to  other  nodes  in  the 
course  of  the  lymph-stream.  However,  retrograde  infection  is 


TUBERCULOSIS  281 

claimed  occasionally  to  be  produced  when  blockage  of  the  usual 
channels  occurs,  and  a  reverse  stream  is  thus  brought  about. 

The  changes  produced  within  the  lymph-nodes  are  of  two  types. 
In  one  there  appear  a  number  of  miliary  tubercles  throughout  the 
substance  of  the  gland,  which,  on  section,  are  visible  to  the  naked 
eye;  while  in  the  other  type,  the  so-called  scrofulous  lymphadenitis, 
there  is  a  hyperplasia  of  the  entire  gland  substance.  They  may 
reach  an  enormous  size.  The  subsequent  course  of  the  second  type 
is  variable;  in  one  case  the  gland  more  or  less  completely  caseates 
and  goes  no  further;  if  the  caseation  involves  the  whole  gland,  "the 
cut  surface  is  dry,  homogeneous,  friable,  fissured,  or  moist  and 


Fig.  48. — Tubercular  lymph-nodes  of  neck. 

yellowish  white"    (Kaufmann).     The   cervical,   mesenteric,   and 

bronchial  nodes  an-  u-ually  affected.  On  the  other  hand,  a  second 
type-  may  pursue  a  very  different  and  much  more  favorable  course, 
in  which  there  is  but  little  tendency  to  caseation  or  softening,  but  a 
continual  increase  in  the  hardness  of  the  nodes.  The  nodes  are 
spar<ely  infected  with  tubercle  bacilli,  run  a  very  chronic  course, 
and  may  reach  the  si/.e  of  a  turkev's  e^g.  "The  cut  surface  of  these 
is  homogeneous,  iila/.ed.  pale,  reddi-h  j:ray,  or  brownish"  (Kauf- 
mann). The  nodes  of  the  neck,  axilla,  and  groin  are  chiefly 
affected. 


282  PRINCIPLES   OF   SURGERY 

Subsequent  Course. — (1)  Tubercular  lymph-nodes  may  heal  by 
destruction  of  the  bacilli  or  by  encysting  them  with  new-formed 
fibrous  tissue.  (2)  The  inflammation  may  extend  and  affect  the 
capsule  of  the  gland  and  the  surrounding  tissue,  forming  a  periad- 
enitis.  This  fixes  the  nodes  immovably,  and,  if  more  than  a  single 
node  is  involved,  mats  the  whole  group  together  into  one  immovable 
mass,  in  which  frequently  no  longer  evidence  of  the  individual 
nodes  is  to  be  had  hi  a  clinical  way.  (3)  Occasionally  the  lymph- 
node  is  relieved  of  the  infection  by  calcification  of  the  gland  par- 
tially or  completely.  (4)  A  very  frequent  course  is  that  so  common 
to  tubercle  elsewhere,  namely,  caseation,  softening,  suppuration, 
and  subsequent  discharge  of  the  contents  to  the  surface  through  a 
sinus  which  may  persist  indefinitely  if  only  a  part  of  the  mass  is 


Fig.  49. — Gross  section  of  tubercular  lymph-nodes  from  neck. 

broken  down  at  the  tune  of  rupture;  for  while  the  lesion  is  relieving 
itself  through  the  sinus  it  may  be  extending  at  the  periphery;  so 
the  sinus  is  maintained.  There  forms,  too,  in  these  cases  a  rela- 
tively great  quantity  of  scar-tissue,  which,  by  contracting,  causes 
such  disfigurement  of  the  neck  as  scarcely  will  be  found  in  any 
other  condition  except  scars  from  burns.  If  burns  can,  therefore, 
be  eliminated,  these  scars  become  almost  diagnostic.  Fortunately, 
they  are  less  frequently  seen  than  formerly.  The  sinuses  from 
these  as  well  as  other  tuberculous  foci  may  heal  temporarily,  but 
they  usually  open  at  a  subsequent  time,  owing  to  further  progress 
of  the  process.  If  the  rupture  of  a  tubercular  abscess  takes  place 
into  a  body  cavity  or  into  a  vein  a  new  local  or  a  general  infection 
takes  place. 

Favorite  Nodes. — It  follows,  from  what  has  been  said  previously, 


TUBERCULOSIS  283 

that  any  lymph-node  may  be  infected  by  tubercle  bacilli.  As 
a  matter  of  fact,  a  few  favorite  sites  embrace  the  vast  majority  of 
cases.  The  nodes  of  the  neck,  especially  those  of  the  anterior 
triangles,  stand  at  the  head  of  the  list  of  the  surgical  cases.  Pos- 
sibly a  greater  number  would  show  bronchial  involvement.  The 
intra-abdominal  nodes,  especially  the  mesenteric  nodes,  may  be 
infected,  particularly  in  children.  The  next  group  is  the  inguinal 
nodes  and,  perhaps  somewhat  less  frequently,  the  axillary  nodes. 
S<  >  t  hat,  from  the  standpoint  of  probabilities,  one  may  be  able  to 
make  a  fairly  correct,  though  still  unreliable,  estimate  that  if  a 
certain  group  of  nodes  is  involved  it  was  or  was  not  caused  by 
tubercular  infection.  Occasionally  the  affection  seems  to  be 
general.  In  tuberculosis  of  the  lymph-nodes  a  single  node  may  be 
involved  or  the  whole  chain;  it  may  be  unilateral  or  bilateral. 
Tin-  history  of  a  preceding  non-tubercular  infection  is  no  argument 
against  tubercular  secondary  infection. 

Diagnosis. — It  is  by  no  means  easy  always  to  recognize  tuber- 
culc  >us  lymph-nodes  as  such,  except  where  they  occur  in  conjunction 
with  definite  tuberculous  processes  in  other  tissues.  The  source 
of  infection  can  often  be  detected,  as,  for  instance,  chronic  enlarge- 
ment of  the  tonsils  or  adenoids,  which  usually  do  not  produce  lymph- 
node  enlargement  unless  they  are  tubercular.  The  groups  of  nodes 
usually  affected  by  tuberculosis  have  been  mentioned  above,  and 
they  bear  a  very  definite  relation  in  most  instances  to  sources  of 
tubercular  infection.  On  the  contrary,  syphilitic  nodes,  with  the 
exemption  of  those  into  which  the  primary  lesion  drains,  show  a  dis- 
tinct and  unexplained  predilection  for  certain  groups,  which,  as  a 
rule,  are  not  very  frequently  affected  by  tubercle — e.  g.,  the  pos- 
terior cervical  chains,  the  epitrochlears,  the  popliteal,  and  the 
inguinal  nodes.  Syphilitic  lymph-nodes  are  discrete,  firm,  mov- 
able, and,  as  a  rule,  not  greatly  enlarged  or  apt  to  soften  or  suppu- 
rate, and  are  painless;  all  these  things  may  happen  to  tubercular 
nodes,  with  the  addition  that  they  often,  if  close  to  the  surface,  show 
redness  of  the  skin. 

Finally,  the  tuberculin  and  Wassermann  reactions  may  be 
employed  with  a  great  degree  of  reliability  as  a  differential  plan 
bet  ween  tubercular  and  syphilitic  processes  in  general. 

TUBERCULOSIS   OF  THE   SEROUS   CAVITIES 
The  serous  surfaces  of  the  body  are.  with  varying  frequency,  all 

su-eeptible  to  tubercular  infection.  They  embrace  the  pleura,  the 
peritoneum,  the  true  joints,  and  the  meninges.  They  are  affected 
in  frequency  in  the  order  given. 

The  Pleurae.-  The  pleural  cavities  are  affected  doubtless  more 
often  than  any  other  serous  cavities,  often  without  being  recog- 


284  PRINCIPLES   OF   SURGERY 

nized,  as  a  study  of  pleurae  in  the  postmortem  rooms  would  lead  us 
to  believe;  this  is  doubtless  often  interpreted  as  pleurodynia. 
Tubercular  pleuritis  may  be  primary,  but  it  is  usually  observed  as 
secondary  to  tuberculosis  elsewhere,  especially  of  the  lungs,  from 
which,  by  direct  extension,  it  is  an  easy  matter  for  the  process  to 
extend  to  the  visceral  pleura.  It  may  arise  hi  a  similar  manner 
from  infected  bones  of  the  thorax  or  from  the  escape  of  a  tubercular 
abscess  into  the  pleural  cavity.  Tubercular  pleuritis  may  mani- 
fest itself  secondary  to  pulmonary  tuberculosis  which  has  produced 
neither  sufficient  physical  signs  nor  symptoms  to  arouse  suspicion. 

The  changes  produced  in  the  pleurae  by  tubercular  infection  are 
manifold.  First,  large  numbers  of  miliary  tubercles  may  cover  the 
pleura  and  produce  an  effusion.  This  is  the  rule  in  primary  tuber- 
culosis. The  exudate  may  be  serous,  sanioserous,  or  serofibrinous. 
The  pleura  is  covered  with  fibrinous  exudate,  and  granulation  tissue 
springs  up  which  is  abundantly  supplied  with  vessels,  and  these  are 
prone  to  bleed  on  the  slightest  provocation,  thus  giving  rise  to 
hemorrhagic  fluids  found  in  these  cases.  If  there  is  a  tuberculous 
cavity,  about  to  rupture  or  already  ruptured  into  the  pleural  sac, 
it  will  likely  give  rise  to  a  suppurative  pleuritis;  in  this  pus  both 
pyogenic  bacteria  and  tubercle  bacilli  may  be  wanting.  The 
presence  of  a  purulent  fluid  in  the  pleura,  with  no  bacteria,  is  almost 
unmistakable  evidence  of  tubercular  pleuritis.  The  fluid  accumu- 
lating in  tubercular  pleurisy  does  not  always  have  free  access  to  the 
whole  cavity,  and  hi  these  instances  requires  care  to  avoid  mistakes 
in  diagnosis;  the  parietal  and  visceral  pleurae  may  adhere  at  a  cer- 
tain level,  waljing  off  a  part  of  the  pleural  cavity,  which  may  be 
filled  with  exudate.  In  all  these  cases  there  may  be  marked  thick- 
ening of  the  pleura  and  the  formation  of  nodes  and  bands  of  con- 
nective tissue,  all  of  which  contain  large  numbers  of  tubercles  and 
are  amenable  to  the  laws  governing  the  pathologic  course  of  tu- 
bercles. 

On  the  other  hand,  tubercular  pleurisy  may  produce  no  free 
exudate,  but  remain  dry  and  fibrinous.  It  is  a  productive  inflam- 
mation. This  fibrinous  material  organizes  and  causes  dense  ad- 
hesions between  the  opposing  pleurae,  so  that  removal  of  the  lung 
becomes  an  impossibility  except  by  stripping  the  parietal  pleura 
from  the  chest  wall.  These  dense  adhesions  are  especially  fre- 
quent at  the  apices,  although  the  base  of  the  lung  is  often  affected. 
It  is  most  frequently  seen  in  cases  of  pulmonary  tuberculosis. 
Caseation  of  the  masses  of  tubercles  and  new-formed  tissue  follow 
this  type. 

The  development  of  tubercular  pleurisy  may  be  rapid  or  slow. 
The  symptoms  are  less  marked,  as  a  rule,  and  the  pain  is  less  intense 
than  in  the  ordinary  non-tubercular  types.  At  the  same  time  the 


TUBERCULOSIS  285 

course  of  tubercular  pleurisy  is  chronic  and  persistent.  It  may  be 
bilateral  in  rare  instances.  When  the  effusion  comes  to  the  point 
of  interfering  with  respiration  and  the  heart's  action  it  is  usually 
easy  to  recognize  its  presence,  especially  if  a  history  of  tuberculosis 
has  been  suspected.  It  is  not  enough  to  recognize  and  to  practice 
local  treatment  hi  these  cases,  their  tubercular  origin  must  be 
demonstrated  if  possible. 

The  Peritoneum. — Tubercular  peritonitis  originates  from 
tuberculosis  of  the  vermiform  appendix.  This  is  claimed  to  be  the 
most  frequent  source  hi  males;  from  the  Fallopian  tubes,  the  most 
frequent  source  hi  females;  from  the  mucous  membrane  of  the 
intestines  by  extension  from  a  tuberculous  ulcer  through  to  the 
peritoneal  coat,  and  from  the  mesenteric  glands  (tabes  mesenter- 
ica),  especially  hi  children.  It  may  be  secondary  to  tuberculosis 
of  other  abdominal  and  pelvic  organs,  as  the  kidneys,  adrenals,  and 
bladder  or  seminal  vesicles,  and  is  rarely  primary.  Tubercular 
peritonitis  is  either  localized  or  general,  probably  always  localized 
at  first  when  secondary  to  disease  of  a  viscus,  and  general  only 
when  it  is  due  to  the  rupture  of  some  tuberculous  focus  into  the 
cavity  and  the  early  diffusion  of  the  discharge,  or  to  the  gradual 
extension  of  the  disease  from  the  first  localized  area.  One  sees,  for 
instance,  hi  tubercular  peritonitis  originating  in  the  appendix 
numerous  tubercles  on  the  appendix  and  caput  cseci,  and  as  one 
leaves  this  focus  the  number  gradually  diminishes  until  no  more 
are  found. 

Types. — There  are,  according  to  the  usual  methods  of  classi- 
fication, three  fairly  distinct  clinical  types  of  tubercular  peritonitis, 
although  it  is  doubtful  if  one  can  claim  that,  from  the  pathologic 
standpoint,  they  are  clearly  enough  separated  from  one  another  to 
justify  a  distinction.  The  ascitic,  the  dry  or  adhesive,  and  the 
ulcerous  types  are  recognized,  as  well  as  a  fourth  rare  type,  latent 
tubercular  peritonitis.  This  classification  may  be  accepted  as 
nominal,  for  many  cases  seen  at  operation  or  postmortem  show 
iiulix-riminate  mingling  of  the  three  types  hi  a  s'ingle  abdomen,  so 
that  the  classification  cannot  be  accepted  as  a  logical  presentation 
of  facts;  it  is  rather  a  device  to  serve  the  purpose  of  teaching. 

Ascitic  Type. — The  ascitic  type  is  very  similar  to  effusive  tuber- 
cular ]>leuri>y.  The  peritoneum  is  more  or  less  thickly  and  widely 
covered  with  tubercles,  and  there  is  an  accumulation  of  fluid  in  the 
peritoneal  cavity,  varying  from  an  indistinguishable  increase  over 
normal  all  the  way  to  the  widest  dist«ntion  of  the  cavity.  This 
fluid  is  serous  or  serosanguinolent.  It  has  free  access  to  the  whole 
cavity  in  typic  cases,  but  hi  the  mixed  cases  may  be  encysted — 
i.  e.,  confined  by  adhesions  to  some  definite  part  of  the  peritoneal 
sac.  The  condition  must  be  distinguished  from  malignant  intra- 


286 


PRINCIPLES   OF   SURGERY 


abdominal  growths,  from  portal  obstruction,  and  leakage  of  the 
chyle  channels  into  the  abdominal  cavity. 

Adhesive  Type. — The  adhesive  type  is  very  common.     In  this 
the  intestines  may  be  so  bound  together  that  they  no  longer  appear 


Fig.  50. — Tuberculosis  oi  the  visceral  peritoneum. 

to  be  intestines,  the  omentum  and  mesenteries  are  shortened,  often 
almost  to  obliteration,  the  coils  of  intestine  are  bound  together  in 


Fig.  51. — Tubercular  ulceration  of  the  mucous  membrane  of  the  small  in- 
testine. 

an  inseparable  mass,  and  the  normal  surface  appearances  are  all 
destroyed.  It  is  impossible  to  lift  such  intestines  from  the  cavity, 
or  to  separate  them  from  one  another  without  great  risk  of  tearing 


TUBERCULOSIS  287 

into  their  lumina  or  destroying  their  blood-supply.  In  portions  of 
the  cavity  not  so  far  advanced  the  fibrinous  exudate,  yellowish  in 
color,  may  be  seen  on  the  inflamed  peritoneum.  There  is  no  free 
exudate;  there  is  no  peritoneum  left  to  produce  one;  the  process  is 
ol>l iterative;  occasionally  fluid  is  found  walled  off  hi  pockets  formed 
by  the  dense  adhesions  and  may  be  serous  or  purulent.  In  the 
ascitic  type  the  abdomen  is  large,  hi  the  adhesive  type  it  is  small, 
often  scaphoid;  hi  the  ascitic  type  there  are  symptoms  and  signs 
of  accumulated  fluid;  hi  the  adhesive  type  these  are  wanting.  In 
the  ascitic  type  the  patient  is  uncomfortable  on  account  of  weight 
an<  1  tension;  hi  the  adhesive,  on  account  of  interference  with  normal 
peristalsis,  which  may  go  to  the  point  of  chronic  intestinal  obstruc- 
tion. In  the  ascitic  type  individual  organs  within  the  abdomen 
may  not  be  palpated;  hi  the  adhesive,  palpation  of  the  distorted  and 
displaced  contents  is  easy,  but  recognition  is  impossible.  The 
omentuMi  may  be  felt  lying  along  the  transverse  colon  like  a  roll. 
In  the  adhesive  type,  hi  addition  to  the  mass  formed  by  contrac- 
tion and  matting  of  the  normal  structures  together,  there  appear 
a  1 -u  at  times  great  masses  of  tissues,  which  from  the  outside  cannot 
be  differentiated  from  tumors.  They  may  attach  to,  or  lie  in, 
various  structures,  but  are  found  especially  hi  connection  with  the 
omentum  and  the  uterine  adnexa. 

Ulcerative  Type. — The  ulcerative  type  is  hardly  worthy  to 
be  classed  as  a  type;  it  is  but  an  advanced  stage  which  may  develop 
in  t  he  adhesive  type;  when  caseation  and  suppuration  of  the  masses 
occur,  there  develop  ulcers  in  the  intestinal  mucosa,  sinuses  leading 
from  the  caseated  masses  into  the  lumen  of  the  gut,  or  to  the  skin 
surfaces,  especially  at  the  navel;  redness,  edema,  and  discharge  of 
pus  and  feces  from  the  navel  are  very  important  diagnostic  signs 
that  rarely  occur  except  hi  tuberculous  peritonitis.  Fecal  ti-tuhe, 
too,  may  be  established  elsewhere. 

Lull  nt  Type. — The  latent  type  needs  to  be  mentioned,  for  it  is 
not  an  unusual  accidental  finding  during  laporatomy  when  no 
suspicion  of  its  presence  had  been  aroused. 

A  moment's  review  of  what  has  been  said  of  the  pathology  of 
tuberculo-i-  in  general,  and  of  the  varieties  of  tubercular  perito- 
niti-.  will  force  the  conclusion  upon  the  reader  that  fundamentally 
they  are  all  the  same,  and  that  it  is  circumstances  and  stages  of 
development  of  the  reaction  of  the  tissues  that  cause  the  variation. 
If  the  peritoneum  i>  not  de-t  roved,  effusion  occurs;  if  it  is  destroyed 
by  plastic  exudates  or^ani/inti  over  its  surface  and  then  contracting, 
a  -<vnnd  picture  is  produced.  If  caseation  of  these  new  products 
occurs  and  then  suppuration — whether  with  or  without  secondary 
infection,  is  immaterial — and  these  products  seek  and  find  no  outlet, 
the  third  picture  follows  logically  ujxm  the  usual  changes  occurring 


288  PRINCIPLES    OF   SURGERY 

in  tuberculosis,  and  results  from  degeneration  and  disintegration 
of  tissue. 

Tuberculous  Synovitis. — This  group  of  serous  surfaces,  espe- 
cially those  of  the  knee  and  the  hip,  is  often  affected  by  tubercular 
infection.  This  must  not  be  considered  the  sole  source  of  tubercu- 
lar joints  (vide  Tuberculosis  of  Bone  and  Cartilage).  The  lesion 
of  the  synovial  membrane  is  similar  to  the  remaining  serous  infec- 
tions. Tubercles  develop,  the  membrane  becomes  thickened,  loses 
its  luster,  and  appears  moist,  thick,  and  spongy.  The  thickened 
mass  is  called  granulations.  Caseating  tubercles  may  be  found; 
tubercle  bacilli  are  scarce  and  difficult  to  find.  There  may  be  an 
exudate  of  clear  serum,  or  it  may  be  fibrinous,  serofibrinous,  or 
purulent.  In  the  fluid  often  appear  yellowish,  elastic,  small 
flattened  bodies,  known  as  rice  bodies.  The  capsule  of  the  joint 
may  be  little  affected  or  completely  destroyed  by  the  process;  in- 
vasion of  the  adjacent  bones  is  possible.  Organization  of  the 
fibrinous  exudate  may  destroy  the  function  of  the  joint.  With  the 
appearance  of  the  inflammatory  process  the  joint  is  more  or  less 
swollen,  painful,  and  impaired  in  function  or  capable  of  motion 
through  a  very  limited  range.  If  effusion  occurs  the  capsule  is 
distended  and  fluctuant,  and  the  joint  is  held  involuntarily  by  the 
patient  in  such  a  position  as  to  give  the  cavity  the  greatest  capacity. 

TUBERCULOSIS  OF  BONE  AND   CARTILAGE 

Tuberculosis  of  bone  is  an  exceedingly  frequent  surgical  con- 
dition. The  infection  reaches  the  bone  largely  through  the  cir- 
culation of  the  blood.  It  affects  spongy  bone  much  more  fre- 
quently than  hard  bone.  It  is,  therefore,  found  usually  in  the  small 
bones,  such  as  the  carpal  and  the  tarsal  bones,  the  vertebrae,  and 
the  cancellous  extremities  of  the  long  bones.  A  favorite  site  for 
tuberculosis  of  bone  in  the  young  is  the  epiphyses  of  the  long  bones. 
This  is  especially  interesting,  as  this  is  the  chief  source  of  tubercular 
arthritis.  In  this  latter  respect  it  is  different  from  osteomyelitis 
produced  by  pyogenic  bacteria,  which  usually  attacks  the  diaphysis 
of  the  long  bones.  The  infection  is  usually  unilocular,  but  may  be 
multilocular.  The  location  of  tubercle  bacilli  at  definite  sites  is 
certainly  favored  by  trauma,  often  so  slight  as  to  be  forgotten,  and 
some  authors  think  that  almost  invariably  some  devitalizing  process 
must  be  presupposed  before  such  infection  is  possible.  There  are 
usually  other  tubercular  lesions  in  the  body,  but  they  are  not  con- 
stant. 

Having  gained  lodgment  in  bone  the  reaction  of  the  tissues 
begins  to  manifest  itself,  either  by  the  formation  of  tubercles  or  by 
the  appearance  of  an  osteomyelitic  focus  of  granulation  tissue,  in 
the  midst  of  which  tubercles  are  found.  Bacilli  are  very  scarce 


TUBERCULOSIS 


L'S'J 


in  those  lesions.  This  granulation  tissue  may  infiltrate  widely  into 
the  tissue  surrounding  the  original  focus.  The  fungoid  mass  of 
granulation  tissue  destroys  the  osseous  tissue  partially  or  com- 
pletely. If  partially,  fragments  of  bone  may  be  left  in  the  mass 
in  the  form  of  bone  sand.  This  is  formed  when  the  granulation 
tissue  cannot  absorb  all  the  bone.  If  the  granulation  tissue  grows 
in  the  lacuna  and  absorbs  their  wall,  and  makes  their  spaces  larger 


Fig.  52. — Caries  of  scapula. 


Fig.  53. — Caries  of  the  spinal  column, 
tubercular. 


by  making  their  walls  thinner,  and  no  suppuration  occurs,  the  con- 
dition is  known  as  dry  caries  (caries  sicca).  If  caseation  is  marked 
and  extensive  (Caseous  tuberculous  osteomyelitis)  the  absorptive 
power  of  the  granulation  tissue  is  at  its  lowest  ebb,  and  gross  speci- 
mens of  bone  are  found  dead  in  situ.  These  sequestra  may  show 
evidence  of  partial  absorption  by  their  irregular,  pitted  surface. 
They  ultimately  t>eeome  completely  separated  from  the  living  bone 
and  lie  in  the  mi<l.-t  of  >urroun«ling  tuberculous  granulations.  The 

19 


290 


PRINCIPLES   OF   SURGERY 


fungus  type  is  seen  usually  in  poorly  nourished,  emaciated  indi- 
viduals. Sometimes  both  types  appear  in  the  same  case.  The 
masses  of  tuberculous  new  tissue  may  remain  unchanged  and  re- 
semble tumor  of  the  bone,  especially  sarcoma,  or  soften  and  sup- 
purate, constituting  a  tuberculous  bone  abscess.  The  limiting  wall 
of  such  an  abscess  is  made  up  of  tuberculous  granulations,  some- 
times called  abscess  membrane  (equivalent  to  "pyogenic  mem- 
brane"). On  the  other  hand,  new  fibrous  tissue  may  develop 
around  the  pus  and  encapsulate  it  so  as  to  produce  at  least  a  tem- 
porary cure.  The  subsidence  of  symptoms  and  apparent  recovery 
does  not  signify  that  the  bacteria  are  destroyed;  they  are  simply 
latent,  and  not  infrequently  are  rekindled  into  a  new  and  often 

more  violent  activity  by  receipt  of 
trauma  at  the  site  of  the  old  focus. 
Spina  Ventosa. — Tuberculosis  of 
the  smaller  bones,  such  as  the  pha- 
langes, metacarpals,  and  metatarsals, 
as  well  as  occasionally  some  of  the 
larger  long  bones,  for  example,  those 
of  the  upper  extremity,  develop  a 
peculiarly  interesting  tubercular  le- 
sion known  as  spina  ventosa.  The 
internal  parts  of  the  bone  are  de- 
stroyed by  absorption,  thus  increas- 
ing the  size  of  the  cavity,  while  the 
periosteum  is  building  new  bone  at 
the  surface.  So  there  is  formed  a 
nodule,  more  or  less  spheric,  hol- 
low, and  of  considerably  greater  di- 
ameter than  the  original  bone. 

Pott's  Disease. — Tuberculosis  of 
the  spine  (Pott's  disease)  produces, 
where  the  bodies  of  the  vertebrae  are 

destroyed,  or  so  softened  as  to  be  unequal  to  the  weight  they  must 
support,  very  characteristic  deformities.  It  is  readily  understood 
that  the  chief  danger  of  such  deformity  lies  in  the  damage  done 
to  the  spinal  cord. 

The  course  of  tuberculosis  of  bone  is  usually  prolonged,  and 
may  last  for  many  years.  Pain  is  the  most  important  symptom, 
and  is,  as  a  rule,  not  violent.  An  enlargement  of  the  bone  may  take 
place  at  the  site  of  infection,  the  location  of  which  in  cancellous 
bone  causes  suspicion  of  the  presence  of  tuberculosis.  The  pus 
may  escape  and  accumulate  underneath  the  periosteum,  or  into 
the  soft  tissues  surrounding  the  bone,  and  either  in  the  vicinity  of 
the  bone  lesion  or  remotely,  after  burrowing  through  more  or  less 


*9n 


Fig.  54. — Ankylosis  of  verte- 
brae in  a  case  recovering  from 
tubercular  caries. 


TUBERCULOSIS  291 

devious  paths,  form  a  cold  abscess.  So  retropharyngeal  abscess  is 
formed  from  tubercular  conditions  of  the  cervical  vertebrae  and 
th»-  hones  forming  the  base  of  the  skull,  and  psoas  abscess  from  the 
dorsal  and  lumbar  vertebrae.  When  tuberculosis  of  the  bones  of 
an  extremity  is  sufficient  to  interfere  with  function,  atrophy  of  the 
extremity  takes  place,  and  its  circumference  is  then  found  to  be  less 
than  that  of  the  sound  side. 

When  bone-sand  forms  in  tubercular  lesions,  the  pus  coming 
through  sinuses  leading  therefrom  has  a  gritty,  unctuous  feel. 
The  sinus  itself  has  an  abundance  of  scar-tissue  in  its  wall,  and  the 
outlet  of  the  sinus  assumes  a  peculiar  elevation  above  the  level  of 
the  skin,  which,  if  cut  away,  is  re-formed  by  the  unhealthy  granula- 
tion. The  mass  of  dead  bone  which  has  been  necrotized  is  known 
as  a  sequestrum.  The  periosteum,  if  intact,  builds  an  envelope 
of  new  bone  around  the  sequestrum,  which  is  called  involucrum. 
The  pus  escapes  through  the  openings  in  the  involucrum,  which  are 
called  doacce.  The  sinus  leading  from  a  diseased  bone,  especially 
if  tubercular,  is  frequently  seen  to  close  or  almost  close,  and  give 
the  impression  that  the  process  has  subsided.  It  is  unsafe  to  give 
too  favorable  a  prognosis  under  these  circumstances,  however,  for 
with  insignificant,  or  with  no  provocation,  the  process  is  kindled 
again  into  activity. 

The  value  of  skiagraphy  in  the  diagnosis  of  tuberculosis  of  bone 
is  very  great,  especially  when  taken  in  conjunction  with  local  and 
MXtstitutional  evidences. 

X-ray  evidences  only  show  the  variations  hi  the  density  of  bone, 
and  cannot  be  accepted  per  se  as  signifying  the  cause  of  such  varia- 
tions.  But  if  the  symptoms,  the  shape  of  the  light  spots,  and  the 
location  be  considered,  then  a  study  of  the  skiagraph  or  of  the 
part  itself  with  the  fluoroscope  assumes  very  important  diagnostic 
worth. 

It  must  be  stated  plainly  that  a  very  grave  mistake  made  by 
physicians  is  the  assumption  that  all  chronic  bone  lesions  are 
tubercular,  especially  if  there  is  marked  swelling  or  a  discharge. 
It  i-  necessary  always  to  consider  especially  typhoid  bone  lesions, 
actinomyco-i<.  and  tumors  of  bone;  frequently,  only  after  an 
exhan>tion  of  clinical  methods,  the  correct  diagnosis  can  be  made  by 
inci-ion  and  microscopic  examination  or  by  the  employment  of 
culture  and  inoculation  te-t>. 

Cartilage.  Cartilage  may  be  attacked  by  tuberculosis  which 
extends  to  it  from  some  neighboring  le-ion.  The  poor  resi.-tance  of 
cartilage  render-  it  ea-ily  dot  roved  by  tuberculosis.  The  chief 
affection  of  cartilage  by  thi>  di-ea-e  i-  in  connection  with  tuhercn- 
lo-U  of  the  joints,  under  which  heading  the  course  of  the  infection 
i-  iriven  more  fully. 


292 


This  is  a  combination  of  tuberculosis  of  the  synovial  membrane 
and  the  articular  cartilage,  or  of  either  independently.  The  serous 
type  has  been  studied  already,  in  connection  with  tuberculosis  of 
the  serous  membranes.  We  have  left  here,  therefore,  only  to  study 
tuberculous  arthritis.  The  sources  of  joint  tuberculosis  are  two: 
the  more  common,  or  osteopathic,  is  seen  in  the  young ;  the  synovial, 


Fig.  55. — Tuberculosis  of  right  knee. 

or  arthropathic,  type  is  more  common  in  adults.  In  either  the  same 
ultimate  results  may  be  produced.  In  the  osteopathic  type  the 
focus  from  which  the  joint  is  invaded  is  the  epiphyseal  cartilages, 
between  which  and  the  articular  cartilage  there  lies  a  very  thin  layer 
of  bone.  Tubercular  epiphysitis,  then,  having  developed,  it  is 
but  a  short  distance  for  the  process  to  extend  into  the  joint,  unless 
by  chance  it  extends  in  a  direction  parallel  to  the  joint  surface  and 


TUBERCULOSIS 


293 


at  t  acks  the  peri-articular  structures.  Even  when  no  invasion  of  the 
joint  can  be  proved,  the  proximity  of  a  focus  of  tuberculosis  in  an 
epipli\>is  may  cause  sufficient  inflammatory  reaction  in  the  joint 
it  >elf  to  produce  a  hydrops,  which  gives  the  joint  the  clinical  appear- 
ance of  having  already  become  invaded  with  tubercle  bacilli. 
Tliis  may  continue  a  few  days  and  then  subside  if  no  invasion 
occurs. 

As  the  destructive  process  of  tubercular  epiphysitis  approaches 
the  joint,  there  forms  on  the  articular  surface  of  the  cartilage  a 


Fig.  5ft. — Tubercular  hip-joint  healed,  with  bony  ankyloeis. 


va-cular  membrane,  pannus  '<imilar  to  the  pannus  formed  on  the 
non-vascular  conic:-.),  which  covers  the-  surface  more  or  less  widely. 
Sufficient  fibrou-  tU-ue  ami  adhesion-  may  thus  he  produced  to  pro- 
tect the  greater  jxirtion  of  the  joint  cavity  from  the  infection;  on  the 
other  hand,  the  pannus  formation  may  fail  to  save  the  joint  cavity. 


294 


PRINCIPLES   OF   SURGERY 


The  focus  now  perforates  the  cartilage  and  the  contents  of  the 
lesion  escape  into  the  joint.  As  a  consequence,  one  of  three  courses 
is  followed.  First,  a  diffuse  tuberculosis  of  the  joint  occurs,  and 
miliary  tubercles  develop  over  the  synovial  membrane,  which, 
together  with  capsule  and  ligaments,  becomes  more  or  less  infil- 
trated and  sometimes  disorganized  into  a  gelatinous  mass,  and 
permits  easy  dislocation  of  the  joint,  or  produces  an  unsteady 
joint,  which  is  movable  to  an  unnatural  degree,  and  fills  the  joint 


Fig.  57. — Tubercular  hip-joint  healed,  with  complete  destruction  of  head  and 

neck  of  femur. 

cavity  with  a  serous  exudate.  Second,  an  unusual  quantity  of 
granulation  material  may  grow  into  and  fill  the  joint  producing  the 
so-called  fungus  type.  Third,  the  tuberculous  masses  may  tend 
to  caseate  and  break  down  into  pus,  which  fills  the  joint  and  may 
escape  through  the  capsule  and  form  peri-articular  abscesses.  This 
unfavorable  type  is  seen  more  frequently  in  the  old. 

As    tubercular    arthritis    advances    the    cartilage    softens,    is 
replaced  by  fibrous  tissue,  which  in  turn  is  permeated  with  tuber- 


TUBERCULOSIS  295 

cles  and  breaks  down,  leaving  the  bone  denuded  of  cartilage  and 
Mil  >j  ret  to  the  ravages  of  continued  spread  or  to  ankylosis,  if 
healing  should  occur. 

It  is,  therefore,  plain  that  in  a  case  of  tuberculosis  of  a  joint, 
effusion,  suppuration,  adhesions,  or  ulceration  may  occur. 

Caries  Sicca. — Caries  sicca  is  said  to  affect  the  cartilage  of 
the  joints,  especially  the  upper  end  of  the  humems.  It  shows 
no  external  signs  of  tuberculosis  or  of  inflammation  and  is  very 
chronic.  The  process  destroys  the  cartilage  and,  in  turn,  is 
destroyed  by  the  healing  process,  which  firmly  ankyloses  the 
joint. 

Signs  and  Symptoms  of  Joint  Tuberculosis. — Pain,  a  very 
important  symptom  of  joint  tuberculosis,  is  always  present,  if 
not  while  the  joint  is  at  rest,  certainly  when  function  is  under- 
taken or  when  extreme  ranges  of  motion  are  attempted,  either 
actively  or  passively.  It  is  not  usually  so  severe  as  hi  acute 
processes  produced  by  pyogenic  bacteria.  Tenderness  is  usu- 
ally present  over  the  joint,  and  is  frequently  more  easily  elicited 
at  certain  points,  especially  when  the  capsule  and  the  associated 
Imrsu'  are  affected.  The  joint  is  almost  invariably  swollen,  and 
this  may  be  due  either  to  the  new  deposits,  to  fluid,  or  to  both; 
ami.  in  contrast  with  the  atrophy  of  the  extremity,  involving  even 
the  bone  in  prolonged  cases,  gives  the  impression  of  an  enormous 
.-welling.  If  the  ligaments  of  the  joint  are  extensively  degener- 
ated a  passive  movement  of  the  joint,  especially  in  unnatural  direc- 
tions (as  in  lateral  movement  of  the  knee-joint),  evinces  the  fact 
that  the  joint  has  become  somewhat  insecure.  Fluctuation  is 
discoverable  in  joints  distended  with  fluid,  but  the  pseudofluctua- 
tion  of  tuberculous  tissues  often  leads  one  to  conclude  that  fluid 
is  present  when  the  aspirating  needle  shows  its  absence.  When 
denudation  of  cartilage  occurs  crepitus  may  be  elicited  on  motion. 
The  knee-  and  hip-joints  are  most  frequently  attacked  and  the 
tarsal  and  carpal  joints,  in  the  order  named,  owing  to  the  great 
requency  of  tubercular  infection  of  the  bones  constituting  these 
joints.  More  or  less  characteristic  attitudes  are  assumed  spon- 
taneoii>ly  when  a  joint  is  inflamed,  and  especially  when  there  is 
a  mass  of  fluid  or  tissue  accumulated  in  the  joint,  and  the  atti- 
tude a-.-unied  is  that  productive  of  the  least  pain,  namely,  one  that 
allows  the  greatest  int racapsular  volume  and  produces  the  light- 
est pressure.  Tuberculosis  of  the  joints  is  said  to  occur  ino>t 
likely  in  the  healthy,  active  child,  rather  than  the  quieter,  frailer 
child,  owing  to  increased  liability  to  injury. 


296  PRINCIPLES   OF   SURGERY 

FASCIA 

The  deep  fascia  may  serve  as  a  focus  for  tuberculous  proc- 
esses, which  usually  terminate  by  producing  cold  abscesses,  and 
these,  owing  to  their  position  and  manner  of  development,  may 
be  easily  mistaken  for  sarcomata. 

KIDNEYS 

The  kidneys  are  frequently  attacked  by  tuberculosis,  usu- 
ally secondarily  to  some  other  form  of  the  disease,  especially  of 
the  lungs,  the  alimentary  tract,  or  bronchial  lymph-nodes;  it  is 
rarely  primary. 

Miliary  tuberculosis  may  attack  the  kidneys  hi  connection 
with  the  general  distribution  of  the  infection,  but  they  are  of  no 
practical  surgical  interest,  as  all  such  cases  die,  regardless  of  the 
plan  of  treatment. 

The  source  of  infection  in  tuberculosis  of  the  kidneys  is  either 
the  blood,  in  which  cases  the  substance  of  the  kidneys  is  affected, 
and  in  which  extension  of  the  infection  to  the  remaining  genito- 
urinary apparatus  may  occur,  descending  urogenital  tuberculosis; 
or  the  form  hi  which  the  other  genito-urinary  organs  may  be- 
come infected  first  and  the  kidneys  secondarily,  ascending  urogeni- 
tal tuberculosis. 

The  usual  hematogenous  form  of  renal  tuberculosis  is  pro- 
duced by  the  lodgment  of  bacilli  in  the  capillaries  and  the  forma- 
tion of  nodules,  which,  by  disintegration  of  the  caseous  masses 
distributed  through  the  kidney-tissue,  form  pockets  of  pus, 
which  may  remain  separate  from  each  other  indefinitely  and 
may  communicate  with  the  pelvis  of  the  kidney,  which  thus 
becomes  infected,  and  produces  a  tuberculous  pyelonephritis. 
More  rarely  they  rupture  on  the  surface  of  the  kidney.  In  this 
form  the  pelvis  is  partially  involved  at  the  beginning,  and  later 
on  becomes  more  or  less  occupied  with  the  tubercular  products, 
and  its  limiting  walls  are  ulcerated.  The  size  of  the  cavities  in 
the  kidney  continues  to  grow  at  the  expense  of  the  parenchyma. 

In  the  ascending  type,  the  pelvis  is  first  affected  and  the 
surfaces  of  the  papilla?  ulcerate;  then  the  process  extends  into 
the  parenchyma  of  the  kidney,  which  ultimately  becomes  com- 
pletely occupied  by  the  developing  tubercles.  They  then  pursue 
their  destructive  degenerative  course  and  empty  their  contents 
into  the  pelvis.  A  tuberculous  kidney  may  be  very  much  en- 
larged throughout  and  show  nodules  over  the  surface,  which 
are  soft  or  hard,  dependent  upon  the  stage  of  degeneration  reached. 
A  rare  form  of  the  disease  shows  the  formation  of  large  nodular 
masses  of  tubercles  which  have  no  tendency  toward  softening. 


TUBERCULOSIS  297 

In  some  cases  of  tuberculosis  of  the  kidneys  lesions  are  found 
extruding  widely  through  their  substance,  but  showing  little  or 
no  evidence  on  the  surface  of  the  organs. 

A  tuberculous  kidney  may  be  considerably  enlarged,  but  this 
is  not  necessarily  so;  the  disease  may  be  unilateral  or  bilateral; 
when  the  latter,  the  stage  of  advancement  is  often  unequal.  If 
a  single  kidney  is  involved  compensatory  hypertrophy  may  take 
place  in  the  other  one. 

The  arteries  supplying  the  kidney  may  become  obstructed  by 
tubercles  and  infarcts  be  produced.  The  process  may  attack  the 
ureter  on  reaching  the  pelvis  and  thicken  it  until  it  becomes  as 
large  as  one's  finger,  or  so  obstruct  its  lumen  as  to  interfere  with 
the  passage  of  urine.  Caseated  foci  may  rupture  into  veins  and 
produce  general  tuberculosis.  The  urine  from  patients  suffering 
from  renal  tuberculosis  usually  contains  pus  and  tubercle  bacilli, 
which  may  be  demonstrated  by  the  microscope  if  they  are  abun- 
dant, or,  if  this  fails,  by  inoculation. 

Local  Signs  and  Symptoms. — The  first  symptoms  complained 
of  are  usually  referable  to  the  bladder — irritability,  strangury, 
frequent  urination.  These  symptoms  appear  without  bladder 
involvement,  but  are  intensified  by  this  complication.  There  is 
usually  enlargement  and  tenderness  of  one  or  both  kidneys;  ten- 
derness is  more  especially  notable  over  the  diseased  organ.  Pain 
is  present  over  the  kidney;  it  is  of  a  dull,  heavy,  aching  character, 
and  may  be  the  first  evidence  of  trouble.  If  the  ureter  becomes 
blocked,  or  when  a  mixed  pyogenic  infection  causes  the  develop- 
ment of  an  abscess,  the  pain  may  become  excruciating.  The  urine 
contain-  pus  frequently  and  blood,  occasionally  in  macroscopic 
quantity,  frequently  in  microscopic  quantity.  The  urine  is  acid. 
In  the  early  stages  of  the  hematogenous  type  there  is  no  pus,  for 
manifest  reasons,  but  when  softening  and  pus  formation  occurs, 
ami  the  ]>u-  is  discharged  into  the  pelvis,  it  shows  abundantly  in 
the  urine;  as  the  quantity  from  a  ruptured  focus  diminishes,  the 
urine  shows  less  and  less  of  it  until  it  perhaps 'disappears  alto- 
gether: the  rupture  of  another  focus  then  causes  an  increase,  and 
so  on.  This  is  the  reason  for  the  necessity  of  repeated  examina- 
tions in  some  cases. 

An  important  item  in  the  recognition  of  tuberculosis  of  the 
kidneys  is  the  remission  of  symptoms  followed  by  a  recurrence. 
During  the  n>mi»ions  the  patient  feels  much  better,  and  may  be 
devoid  of  local  or  constitutional  symptoms;  even  the  general  con- 
dition may  l>e  much  improved. 

Cystoscopy  often  reveals  a  picture  which  indicates  disease  of 
one  or  both  kidneys,  in  the  form  of  an  ulcerative  or  inflammatory 
zone,  at  or  immediately  surrounding  the  ureter  of  the  diseased 


298  PRINCIPLES    OF   SURGERY 

side.  Further  evidence  is  obtained  by  ureteral  catheterization, 
from  which  may  be  learned  the  relative  amounts  and  the  physio- 
logic and  pathologic  characteristics  of  urine  from  the  two  kidneys. 

TUBERCULOSIS  OF  THE  TESTICLES 

The  testicles  are  frequently  tubercular,  and  hi  cases  of  pul- 
monary tuberculosis,  when  no  discoverable  lesion  exists  in  the 
testicle,  the  bacilli  may  be  discovered  hi  the  seminal  vesicles  or 
in  the  seminal  tubules  of  the  testicle,  which  shows  how  readily 
hi  such  cases  an  inflammation  or  a  trauma  might  kindle  into  ac- 
tivity tuberculosis  of  these  glands.  The  epididymis  is  usually  at- 
tacked at  first,  and  the  process  here  begins  usually  hi  the  epi- 
thelium or  the  walls  of  the  tubules,  although  it  may  originate  in 
the  connective  tissue.  The  process  may  begin  in  the  testis  proper. 
Usually  the  condition  is  secondary  to  other  tuberculous  foci,  but 
seems  occasionally  to  be  primary.  When  testicles,  prostate,  and 
seminal  vesicles  are  all  involved,  the  usual  order  of  invasion  is 
testicles  first,  then  vas  deferens,  seminal  vesicles,  and  prostate; 
on  the  contrary,  tubercular  epididymitis  is  rarely  secondary  to 
lesions  in  these  structures.  The  nodule  usually  appears  first 
in  the  head  or  the  tail  of  the  epididymis,  and  slowly  and  pain- 
lessly (or  nearly  so)  enlarges,  undergoing  the  changes  already  de- 
scribed for  tubercle  hi  general.  The  process  may  remain  confined 
to  the  epididymis  for  a  long  time,  or  it  may  invade  the  body  of 
the  testicle.  When  this  occurs  several  nodules  may  develop — 
rarely  a  uniform  enlargement  may  occur — and  produce  consider- 
able increase  hi  the  size  of  the  organ,  exceptionally  up  to  the  size 
of  a  goose's  egg.  The  tunica  vaginalis  may  be  invaded  and  a 
moderate  hydrocele  develop,  or  the  visceral  and  parietal  layers 
may  adhere  and  the  scrotal  tissue  be  invaded  by  the  infection. 
Caseation  and  softening  occur;  if  the  process  has  approached  the 
surface,  the  skin  becomes  reddened  and  rupture  of  the  abscess 
takes  place,  establishing  a  chronic  sinus,  through  which  the  de- 
generated substance  of  the  mass  and  the  destroyed  testicular 
tissue  is  poured.  On  the  other  hand,  the  substance  of  the  testicle 
may  be  completely  destroyed  and  remain  for  a  long  time  within 
the  tunica  albuginea.  When  sinuses  develop,  or  where  healing 
occurs,  there  remains  a  considerable  quantity  of  fibrous  tissue, 
constituting  a  deforming  cord  in  the  former,  a  nodule  or  group  of 
nodules  in  the  latter  case.  The  vas  deferens  is  often  invaded  and 
appears  nodular  or  moniliform,  like  a  string  of  beads  in  which 
the  beads  are  rather  far  apart,  a  condition  which,  when  present, 
is  very  characteristic;  it  is  simulated  by  no  other  lesion  of  the  sper- 
matic cord.  Later,  the  prostate  and  seminal  vesicles  may  become 


TUBERCULOSIS 

involved  and  show  no  signs  or  symptoms.  They  may  be  dis- 
covered by  palpation  per  rectum.  Sufficiently  frequent  subse- 
quent involvement  of  the  second  testicle  is  seen  to  impress  the 
necessity  of  close  attention  to  this  condition.  It  may  occur  at 
widely  varying  intervals  after  the  first  lesion,  and  is  always  to  be 
considered  in  treatment  and  in  making  a  prognosis. 

THE   GENERAL   SYMPTOMS  OF  SURGICAL  TUBERCULOSIS 

Tuberculosis,  like  other  infections  whose  extent  of  involve- 
ment varies  widely,  will  produce  constitutional  symptoms  in 
proportion  to  the  impression  the  toxins  make  on  the  general 
nutritional  processes  and  the  reaction  called  forth.  In  certain 
instances,  where  the  infection  is  slight  or  of  attenuated  virulence, 
or  where,  by  virtue  of  the  anatomic  structure  or  the  pathologic 
change  in  the  tissues,  the  rate  of  multiplication  of  the  bacteria  is 
inhibited  and  the  absorption  of  poisons  retarded,  the  symptoms 
arc  insignificant  or  wanting.  The  truthfulness  of  this  statement 
may  be  illustrated  easily  by  recalling  that  the  majority  of  ap- 
parently healthy  people  have  been  at  some  time  infected  with- 
out having  shown  symptoms  to  call  their  attention  to  the  struc- 
ture, or  to  cause  the  physician  to  suspect  the  true  condition 
umlrr  the  most  skilful  examination.  There  are  intermediate 
cases  which  produce  clear  symptoms  of  moderate  degree  and 
after  a  time  recover;  and,  finally,  cases  which  progressively, 
sometimes  slowly,  sometimes  with  astonishing  rapidity,  cause 
exhaustion,  emaciation,  and  death.  The  constitutional  condi- 
tion cannot  be  said  to  be  an  accurate  measure  of  the  local  danger, 
for  a  small  focus  may  in  one  instance  produce  marked  general 
symptoms,  while  an  extensive  lesion  in  another  instance  may 
call  forth  an  insignificant  reaction.  This  depends  largely  on 
secondary  infections,  the  symptoms  which  may  arise  from  de- 
struction of  the  organ  or  tissue  affected,  and  on  accidents,  such 
us  hemorrhages  or  pressure  of  large  new-formed  masses  on  their 
environs. 

The  symptoms  growing  out  of  such  interference  with  histo- 
logic  structures  or  disturbance  of  function  are  accidental;  those 
dependent  upon  the  presence  of  tubercle  bacilli  in  the  tissues 
— ential,  and.  other  things  being  equal,  should  appear  where- 
evct  the  focus  of  infection  may  be;  they  depend  on  the  absorption 
of  tubercular  poisons.  Patients  who  are  suffering  from  a  severe 
fncu-s  of  tuberculosis  are  emaciated  unless  the  condition  is  acute, 
and  continued  lass  of  flesh  and  strength  without  apparent  cause 
should  always  lead  to  invest  i.irat  ion  for  this  source  of  trouble. 
Children  who,  in  spite  of  proper  nutrition  and  hygiene,  fail  to  de- 


300  PRINCIPLES   OF   SURGERY 

velop  normally  should  cause  suspicion  of  some  latent  focus,  prob- 
ably in  the  tonsils,  adenoids,  or  the  cervical  lymph-nodes.  Loss 
of  strength  is  associated  with  loss  of  weight,  and  the  patients 
often  complain  of  shortness  of  breath  and  poor  endurance  on 
exercise.  It  is  fortunate  that  in  tubercular  lesions  local  evidences 
have  already  indicated  the  presence  of  trouble,  and  perhaps  its 
nature,  before  these  general  symptoms  arise. 

The  temperature  of  tubercular  patients  may  run  a  normal 
or  nearly  normal  course  until  the  disease  has  gamed  a  firm  hold. 
Usually,  however,  there  is  more  or  less  disturbance  of  the  tem- 
perature, which  runs  a  diurnal  intermittent  course.  There  is  a 
slight  rise  in  the  afternoon,  usually  99|°  to  101°  F.,  but  at  times 
running  much  higher;  while  in  the  morning  the  temperature  is 
subnormal,  97°  to  98°  F.  This  subnormal  morning  temperature  is 
considered  to  be  quite  as  characteristic  as  the  evening  rise.  The 
higher  degrees  of  temperature  are  due  to  violent  or  well-advanced 
infections,  or  to  mixed  infection,  which  is  always  responsible  for 
the  septic  course  observed  in  the  advanced  cases.  The  secondary 
infection  is  sometimes  due  to  accidental  causes,  but  hi  the  major- 
ity of  surgical  cases  it  is  doubtless  due  either  to  the  accidental 
formation  of  sinuses  or  to  unwise  methods  of  interference  on  the 
part  of  the  surgeon.  In  many  cases  of  tubercular  infection,  such, 
for  example,  as  tubercular  peritonitis,  the  temperature  is  never 
observed  to  run  high,  and  death  comes  as  the  result  of  gradual 
exhaustion  of  the  physical  resources. 

There  are  general  characteristics  which  cause  the  careful 
observer  to  think  of  tuberculosis,  of  which  the  long  narrow  chest, 
with  an  angle  of  less  than  90°  between  the  costal  margins  at  the 
epigastrium,  the  pale,  anemic  appearance,  the  peculiar  clubbed 
ends  of  the  fingers,  and  curved  talon-like  nails,  the  pale,  hard  and 
soft  palate,  and  the  roughened  pharynx,  due  to  excessive  adenoid 
tissue,  usually  associated  with  hypertrophied  tonsils,  are  ex- 
amples. These  are  suggestive;  they  cannot  be  accepted  as  diag- 
nostic. If,  hi  addition  to  these  factors,  there  is  a  tuberculous 
heredity,  a  history  of  attendance  upon  or  association  with  tuber- 
cular patients  under  ordinary  unhygienic  surroundings,  or  of 
abode  in  a  house  that  is  or  has  been  inhabited  by  tubercular  sub- 
jects, the  evidence  is  more  favorable  for  a  positive  diagnosis. 

Tuberculin  Tests. — The  presence  of  tuberculosis  in  the  body 
may  be  detected  by  the  employment  of  one  of  the  numerous 
tuberculin  tests  now  in  general  use.  They  are  not  altogether 
reliable,  but  can  be  made  to  justify  almost  absolute  conclusions 
when  they  are  fully  understood.  All  of  them  depend  on  either 
a  local  or  a  general  reaction  to  tuberculin  preparations.  They 
react  to  actinomyces,  and  recently  a  series  of  reported  cases 


TUBERCULOSIS  301 

would  indicate  that  one  of  them  at  least  (von  Pirquet's)  reacts 
to  syphilis.  Failure  to  obtain  a  frank  reaction  in  tubercular  cases 
may  be  due  to  the  species  of  bacilli  causing  the  disease.  For 
example,  avian  or  bovine  infections  in  man  respond  but  slightly, 
or  not  at  all,  to  human  tuberculin.  The  local  tests,  von  Pirquet's, 
Calmette's,  and  Moro's,  only  indicate  that  tubercle  bacilli  are 
pn-ent  somewhere  hi  the  body;  they  offer  no  clue  to  the  site  of 
infection.  The  rapidity  and  extent  of  the  reaction  indicates 
roughly  the  degree  of  intensity  of  the  infection.  The  general 
reaction  obtained  by  hypodermic  administration  of  compara- 
tively large  doses  of  tuberculin  likewise  indicates  the  presence  of, 
but  not  the  part  affected  by,  tuberculosis;  however,  if  the  sus- 
pected lesion  is  observed  closely  this  method  may  be  made  to 
indicate  both  the  presence  and  the  site  of  the  infection;  for,  when 
given  in  sufficient  dosage,  hypodermic  administration  of  tuber- 
culin will  not  only  serve  to  increase  the  general  symptomatology, 
but  also  renders  the  local  tubercular  condition  more  active;  for 
instance,  the  tuberculous  sinus  may  give  out  a  greater  discharge, 
and  the  tubercular  joint  may  increase  in  size  and  become  more 
painful. 

PROGNOSIS   OF  TUBERCULOSIS 

From  a  surgical  standpoint  the  prognosis  of  tuberculosis  is 
good,  provided,  as  in  those  cases  belonging  to  the  internist, 
the  condition  has  not  been  allowed  to  progress  too  far  locally  or 
to  become  general.  There  are  few  cases  that  offer  no  hope,  unless 
they  have  reached  a  dire  extremity.  There  is  always  danger,  hi 
surgical  tuberculosis,  of  the  disease  becoming  general,  or  of  its 
attacking  the  lungs,  the  meninges,  or  some  structure  not  amen- 
able to  surgical  treatment,  as  happens  when  a  second  kidney  is 
invaded.  The  prognosis  is  unfavorably  altered  when,  by  surgical 
interference  or  by  accident,  pyogenic  bacteria  gain  access  to  a 
tuberculous  focus  which  cannot  be  completely  removed  by  surgical 
measures. 

TREATMENT  OF  TUBERCULOSIS 

Many  of  the  tubercular  processes  which  sometimes  belong  to 
surgery-  are  coming  to  be  more  and  more  recognized  as  medical 
conditions.  However,  at  present,  it  is  deemed  wise  to  lay  down 
the  fundamental  principles  governing  the  treatment  of  admit- 
tedly surgical  c:ises,  with  this  understanding,  namely,  that,  as 
a  rule,  when  a  tubercular  lesion  can  be  cured  by  other  means 
more  frequently  than  by  surgical  it  should  not  be  operated  on. 
Furthermore,  it  may  be  laid  down  broadly  that,  while  only  a 
limited  number  of  tuberculous  processes  are  to  be  accepted  as 


302  PRINCIPLES   OF   SURGERY 

amenable  to  surgical  treatment,  all  of  them  should  be  subjected 
to  a  rational  medicinal,  hygienic,  and  dietetic  treatment  before, 
during,  and  after  the  time  they  are  under  the  surgeon's  care. 
The  proper  selection  of  cases  of  tuberculosis  for  operative  treat- 
ment presents  often  one  of  the  most  difficult  problems  the  physi- 
cian has  to  solve.  The  treatment  of  tuberculosis  is  then  subdi- 
vided into  general  and  operative. 

General  Treatment  of  Surgical  Tuberculosis. — It  has  been 
too  long  accepted  without  question  that  cases  of  surgical  tuber- 
culosis were  purely  surgical  cases.  As  the  mode  of  action  of  bac- 
teria, in  whatever  tissue  they  might  lodge,  has  been  more  per- 
fectly understood,  and  the  possibility  of  extension,  especially  of 
tubercular  bacteria,  into  other  fields  near  or  remote  has  been 
accepted  as  one  of  the  great  dangers  of  this  disease,  the  necessity 
for  more  than  local  surgical  treatment  has  impressed  itself  upon 
the  minds  of  the  profession,  until  now  it  may  be  stated  broadly 
that  general  treatment  of  surgical  tuberculosis  is  as  necessary  to 
consummate,  as  the  surgical  treatment  is  to  initiate,  a  cure. 
Hence,  the  surgeon,  if  he  will  serve  his  patrons  best,  must  either 
institute  and  direct  such  treatment,  or  turn  them  into  competent 
medical  hands  who  will  direct  a  regime-  of  treatment  to  be  con- 
tinued, often  indefinitely,  after  recovery  from  his  operative  pro- 
cedures. This  general  treatment  consists  in  hygiene,  diet,  and 
the  use  of  reconstructive  tonic  therapy  and  increase  of  the  specific 
resistance  of  the  patient,  and  can  only  be  satisfactorily  executed 
when  the  patient  understands  as  fully  as  possible  not  only  the 
nature  of  his  malady,  but  the  intention  of  the  plan  of  treatment. 
The  diet,  hygiene,  and  general  conduct  of  the  patient,  the  em- 
ployment of  general  tonic  therapy,  and  the  best  plans  for  meeting 
complications  are  given  in  all  standard  works  on  the  practice  of 
medicine,  and  need  not  be  repeated  here.  The  specific  treatment, 
however,  I  deem  it  wise  to  give  here  as  bearing  especially  on  the 
cure  of  surgical  cases. 

Specific  Treatment. — The  administration  of  tuberculin  in 
various  forms  for  the  cure  of  tuberculosis,  after  passing  through 
a  prolonged  heated  discussion  and  repeated  futile  efforts  to 
establish  its  therapeutic  value,  was  practically  given  up  as  a  for- 
lorn hope  for  a  long  number  of  years,  and  has  only  recently  been 
established  upon  a  trustworthy  footing.  It  is  important,  too,  to 
mention  the  reason  for  failure  in  the  beginning,  namely,  that  it 
was  administered  in  too  large  or  too  frequent  doses.  It  is  by 
virtue  of  competent  use  of  tuberculin  that  so  many  cases  of 
formerly  surgical  tuberculosis  have  been  successfully  treated 
without  operation.  In  this  way  tuberculosis  of  the  lymph-nodes, 
incipient  renal  tuberculosis,  tuberculosis  of  the  testicles,  and  of 


TUBERCULOSIS  303 

the  joints  especially,  has  been  treated  with  very  great  satisfac- 
tion. 

Tuberculin  must  be  administered  hypodermically,  and  should 
always  be  given  by  a  competent  physician,  never  by  the  patient 
himself,  as  is  permitted  sometimes,  for  not  only  is  there  constant 
danger  of  contaminating  the  stock  from  which  the  dose  is  taken, 
but  accurate  supervision  of  the  effect  produced  on  the  patient  and 
watchfulness  for  contra-indications  must  be  had.  Individuals 
who  run  a  maximum  daily  temperature  of  more  than  100°  F. 
should  either  not  receive  this  treatment  until  the  temperature 
has  been  brought  down  under  rest  and  proper  diet,  or  should 
receive  it  only  under  the  frequent  observation  and  charting  of 
temperature,  pulse,  and  general  symptoms.  Any  unfavorable 
symptoms  resulting  from  the  administration  of  tuberculin  calls 
for  its  withdrawal  if  the  dose  is  small  or  its  reduction  if  large. 
It  is  unnecessary  to  make  opsonic  indices  as  a  guide  to  this  treat- 
ment; the  clinical  course  is  sufficient.  The  injection  should  not 
be  made  frequently  at  the  same  point,  for  the  tissues  will  become 
inflamed  and  indurated  and  a  small  sterile  abscess  may  develop 
at  these  places.  Such  abscesses  need  not  be  opened  when  found, 
as  they  will  disappear  hi  a  few  weeks  if  left  alone.  Their  appear- 
ance is  not  a  contra-indication  to  the  continued  use  of  tuberculin. 
Tuberculin  is  administered  hi  doses  varying  from  one  ten-thou- 
sandth of  one  milligram  to  a  maximum  of  one  hundred  milligrams. 
Few  individuals,  comparatively,  are  able  to  take  the  maximum 
dose,  even  when  a  gradual  increase  to  the  maximum  has  been 
made.  But  when  the  reaction  indicates  that  a  maximum  has 
been  reached,  further  increase  hi  dosage  should  not  be  attempted, 
at  any  rate  for  several  doses,  and,  if  undertaken  at  all,  it  must 
be  with  the  utmost  vigilance.  Overdosage  produces  the  same 
symptoms  and  signs  mentioned  under  the  employment  of  tuber- 
culin for  diagnostic  purposes.  The  interval  between  doses  is 
four  or  five  days.  If  the  patient  cannot  come  for  treatment  on 
tin  proper  day,  it  is  better  to  make  the  interval  a  day  more  rather 
than  a  day  less.  If  for  any  reason  the  treatment  is  abandoned 
for  a  time  and  then  renewed,  the  next  in  the  series  of  doses  should 
not  be  given,  but  a  much  smaller  dose;  if  the  interval  has  been 
very  long,  it  is  better  to  begin  at  the  smallest  dose.  The  rate 
of  increase  in  dosage  is  important  when  the  commercial  tuber- 
culins are  u-i  d  according  to  directions  given  with  each  bottle; 
the  increase  over  the  preceding  dose  varies  all  the  way  from  100 
per  cent,  in  the  M-cond  dose  from  each  phial  to  about  10  per  cent. 
for  the  tenth  dose.  Therefore,  physician-  administering  t  hi-  remedy 
should  not  confine  themselves  to  set  instructions,  hut  determine 
the  amount  of  increase  for  themselves  in  each  individual  case. 


304  PRINCIPLES   OF   SURGERY 

It  is  impossible  to  know  when  a  patient  has  taken  tuberculin 
long  enough,  except  by  symptoms,  signs,  and  laboratory  findings. 
It  is  better,  however,  to  continue  its  use  too  long  than  to  stop  too 
soon;  and,  after  cessation,  occasional  observation  of  the  general 
and  local  condition  should  be  made  to  make  sure  that  no  recru- 
descence takes  place. 

Heliotherapy. — The  latest  advance  made  in  the  treatment  of 
surgical  tubercular  lesions  is  by  exposure  to  the  sun's  direct  rays. 
It  is  claimed  for  this  plan  of  treatment  that  it  gives  more  satis- 
factory results  than  any  or  all  of  the  methods  previously  em- 
ployed, without  the  mutilating  effects  of  surgery.  The  per- 
centage of  cures  and  improvements  is  higher  than  is  seen  under 
any  other  plan  of  treatment.  The  treatment  is  especially  applic- 
able to  tuberculosis  of  bones  and  joints,  and,  it  would  seem,  to 
other  superficial  forms  of  the  disease.  The  few  cases  personally 
treated  in  accordance  with  this  method  have  made  marvelous  im- 
provement. The  plan  is  simply  to  expose  the  naked  structures  to 
the  sun's  rays  as  long  as  possible  each  day.  At  the  beginning  the 
exposures  should  be  for  a  brief  period  each  morning  and  evening, 
with  a  gradual  increase  of  tune  as  tolerance  is  established.  This 
plan  is  not  to  be  considered  the  only  valuable  treatment,  but  it 
has  proved  of  such  unmistakable  value  as  to  demand  its  em- 
ployment whether  surgery  is  done  or  not.  It  is  probably  the 
most  important  aid  the  surgeon  has  discovered  to  hasten  and 
insure  complete  recovery  subsequent  to  operation. 

Surgical  Treatment. — The  surgical  treatment  of  tuberculosis 
may  be  subdivided  into  operative,  with  removal  of  focus  or  organ 
containing  it;  operative,  without  removal  of  the  focus,  and  non- 
operative. 

(1)  It  was  formerly  considered  wise  to  largely,  sacrifice  any 
tissue  that  had  become  tuberculous,  and  frequently  the  whole 
organ  hi  which  the  disease  appeared.  This  is  partially  true 
still.  When  the  tissues  have  been  destroyed,  when  caseation  or 
suppuration  has  occurred,  and  when  an  extensive  invasion  has 
developed  in  a  structure,  it  is  best  to  remove  the  diseased  tissue. 
If  the  structure  of  the  part  would  be  worthless  after  removal  of 
the  diseased  tissue  the  organ  itself  is  removed,  provided  its  func- 
tion can  be  satisfactorily  replaced  by  another  organ  of  the  same 
or  a  different  kind.  Before,  however,  a  nephrectomy,  for  ex- 
ample, is  done  it  is  extremely  important  to  measure  the  capacity 
of  the  other  kidney  and  to  know  its  condition.  In  tuberculosis 
of  bone,  where  large  areas  of  bone  tissue  have  necrosed,  total  or 
partial  removal  is  imperative,  and  in  certain  instances  an  ampu- 
tation or  bone-grafting  is  necessary,  owing  to  the  loss  of  usefulness 
excision  would  entail.  It  is  an  excellent  plan  in  tuberculosis  of 


TUBERCULOSIS  305 

structures  that'can  be  spared  without  detriment,  and  where  there 
is  reasonable  assurance  that  the  whole  disease  can  be  removed,  to 
lose  no  time  in  waiting.  This  is  especially  true  of  tuberculous 
abscesses  which  have  not  been  infected  by  secondary  invasion. 
But ,  in  order  for  this  plan  to  be  feasible,  not  only  the  abscess,  but 
the  focus  at  which  the  pus  is  produced,  shall  be  accessible  to  such 
treatment.  If  such  abscesses  are  not  dealt  with  they  may  rupture, 
and  the  prognosis  is  seriously  harmed  by  secondary  infection. 
In  those  cases  hi  which  the  primary  lesion  is  removable,  but  from 
which  other  lesions  have  occurred  secondary  to  it  which  are  not 
amenable  to  surgery,  the  indication  is  to  remove  the  primary 
lesion,  and  subsequently  the  secondary  foci  often  become  much 
more  amenable  to  non-operative  treatment.  An  instance  of 
this  kind  is  the  removal  of  a  tuberculous  appendix  or  Fallopian 
tubes  for  the  relief  of  tuberculous  peritonitis  originating  in  these 
structures,  or  the  removal  or  resection  of  a  tuberculous  testicle 
after  the  seminal  vesicles  and  prostate  have  been  invaded. 

In  removing  tuberculous  bone-tissue  it  is  wise  to  leave  all 
the  sound  bone  possible,  and,  if  this  cannot  be  done,  the  perios- 
teum at  least  should  be  spared.  The  defect  hi  the  bone  may 
be  treated  by  packing  it  open  with  gauze,  many  surgeons  pre- 
fering  iodoform  gauze,  and  allowing  it  to  heal  by  second  inten- 
tion, or  by  filling  the  cavity  with  various  substances.  This  plan 
of  obliterating  the  cavity  after  removal  of  dead  bone  depends 
for  its  success  on  the  absence  or  the  removal  of  pyogenic  infec- 
tion. The  cavity  may  be  closed  and  allowed  to  fill  with  blood- 
clot,  but  this  is  likely  to  prove  unsatisfactory  hi  large  cavities, 
owing  to  danger  of  incomplete  organization.  It  may  be  filled 
with  bone-chips  or,  better  still,  with  decalcified  bone-chips,  made 
preferably  from  cancellous  bone,  or  the  cavity  may  be  filled  with 
a  preparation  of  wax  containing  iodoform  and  hardening  at  a 
temperature  above  that  of  the  body.  If  large  portions  of  bone 
:ir<  removed  the  defect  is  most  satisfactorily  relieved  by  bone- 
grafting. 

In  tuberculosis  of  the  joints,  if  the  joint  cavity  is  destroyed 
and  recovery  cannot  occur  without  invasion  of  the  joint,  excision 
of  the  joint  is  done,  and  an  attempt  made  to  remove  all  disease 
extending  into  the  osseous  tissue  and  to  approximate  the  bones 
for  ankylosis  in  one  instance,  or  to  separate  them  and  interpose 
some  foreign  substance  as  paraffin  in  some  of  the  smaller  joints, 
or,  preferably,  a  dissected  flap  from  adjacent  tissues  for  the  pur- 
pose of  preventing  ankylosis,  as  has  been  done  by  Murphy,  by 
the  interposition  of  flaps  of  fat  between  the  cut  bone  surfaces. 

When  it  becomes  necessary  to  remove  tuberculous  lymph- 
nodes  they  are  dissected  out,  preferably  by  the  block  method;  it 
20 


306  PRINCIPLES   OF   SURGERY 

is  impossible  to  clean  them  away  thoroughly  by  enucleating 
one  at  a  time.  Tuberculous  tonsils  and  adenoids  should  be  enu- 
cleated completely. 

Operation  Without  Removal  of  the  Focus. — From  what  has  al- 
ready been  said  of  tuberculosis  it  will  be  readily  understood  that 
many  surgical  tuberculous  lesions  are  not  susceptible  to  the 
ideal  practice  of  complete,  or  even  an  advantageous  partial, 
removal  of  the  pathologic  tissue.  But  many  of  these  are  to  be 
benefited,  often  cured,  by  operative  measures.  In  some  instances 
operation  is.  necessary  purely  for  the  comfort  of  the  patient  and 
to  avoid  interference  with  vital  processes.  Hence,  effusion  of 
serum  or  pus,  as  the  case  may  be,  if  abundant  must  be  drawn  away 
by  aspiration  or  incision  in  tuberculous  pleurisy,  peritonitis,  or 
synovitis. 

Tuberculosis  of  the  peritoneum,  unless  too  well  advanced,  is 
frequently  cured  by  simply  opening  the  abdomen.  The  chances 
of  cure  are  materially  increased  if,  at  the  same  time,  the  primary 
focus  can  be  determined  and  removed.  It  is  necessary  to  bear  hi 
mind,  however,  that  the  intestines  are  very  friable  when  infil- 
trated by  a  tuberculous  infection,  and  hence  do  not  hold  sutures 
well,  and  that  drainage  of  the  cavity  should  be  made  only  under 
imperative  demands,  for  the  crippled  intestinal  walls  yield  readily 
to  traumata,  and  a  fecal  fistula  that  cannot  be  healed  may  be 
produced  by  the  drainage  material;  in  fact,  as  has  already  been 
mentioned,  such  fistulse  may  develop  in  the  course  of  the  disease 
without  outside  assistance.  How  tuberculous  peritonitis  is  bene- 
fited by  laparotomy  is  not  known.  The  ascitic  type  is  the  most 
amenable  to  this  as  well  as  other  methods  of  treatment. 

The  most  recent  advance  in  the  treatment  of  tubercular 
peritonitis  is  to  paint  the  diseased  peritoneal  surfaces  with  tinct- 
ure of  iodin.  This  plan  gives  apparently  much  better  results  than 
simple  laparotomy. 

Tuberculosis  of  the  pleura  is  treated  by  operation  for  relief 
of  collateral  symptoms  when  fluid  accumulates.  So  long  as  the 
fluid  is  watery  this  treatment  is  satisfactory,  and  may  be  re- 
peated pro  re  nata.  If  aspiration  shows  the  fluid  to  be  pus,  then 
the  treatment  should  be  by  the  open  method  with  drainage.  The 
injection  of  formalin,  2  per  cent,  in  glycerin,  as  recommended  by 
Murphy,  may  be  employed  in  either  of  these  types  after  aspiration, 
and  repeated  until  symptomatic  cure  results,  but  failure  to  pro- 
duce a  cure  is  frequent. 

Tuberculosis  of  the  joints  is  susceptible  of  the  same  methods 
of  treatment  as  have  been  given  under  pleurisy.  The  joint  may  be 
simply  aspirated;  it  may  be  aspirated  and  injected  with  2  per  cent, 
formalin  in  glycerin  or  10  per  cent,  iodoform  emulsion  in  glycerin; 


TUBERCULOSIS  307 

hnmobiluation  is  to  be  employed  in  conjunction.  If  these  plans 
fail,  and  if  the  fluid  is  purulent,  it  may  become  necessary  to  open 
th<-  joint  and  do  such  radical  work  as  the  pathology  indicates. 

Tuberculosis  of  the  testicles  has  until  recently  been  accepted 
as  a  positive  indication  for  castration.  Now  castration  is  done 
when  involvement  of  the  testicle  is  extensive,  and  when  the  vas 
dcf< -rons  shows  nodules  along  its  course,  but  if  only  a  part  of  the 
tr-tirle  or  epididymis  is  affected,  resection  of  the  diseased  tissue 
under  guidance  of  close  inspection  at  the  time  may  save  the  pa- 
tient from  further  extension  of  the  disease  and  from  emasculation. 

Tuberculous  abscesses,  which  belong  to  the  wandering  or  gravi- 
tative  type,  present  a  most  difficult  problem,  and  one  fraught  with 
ujeat  danger  to  the  patient's  life  and  great  and  often  unending 
annoyance  to  the  surgeon.  The  most  important  lesson  to  learn 
about  them  is  that  they  should  not  be  opened  and  drained,  for 
thi-  guarantees  secondary  infection,  which  multiplies  the  danger. 
Second,  they  should  not  be  allowed  to  rupture  of  their  own  accord 
or  even  to  approach  too  near  the  skin  surface,  for  in  the  one 
in>tance  they  are  sure  to  become  infected  with  pyogenic  bacteria, 
and  in  the  other  they  are  very  likely  to.  If  by  means  of  rest, 
Immobilization,  and  general  treatment  they  can  be  prevented 
from  further  increase  in  size  or  encroachment  upon  a  surface 
they  should  be  left  rigidly  alone.  If  they  continue  to  enlarge 
or  to  approach  the  surface,  or  if,  by  virtue  of  their  location,  they 
arc  interfering  with  some  important  function,  or  are  likely  to  do 
so.  they  must  be  subjected  to  operative  treatment.  Aspiration 
has  Ix-cn  often  practised,  but  it  offers  all  the  dangers  and  few  of 
the  advantages  of  open  incision.  These  abscesses  should  not  be 
inci-ed  at  their  thinnest  point,  unless  the  tissues  at  that  point 
are  thick  enough  to  allow  firm  suturing  of  the  cut  edges.  The 
aK-ress  cavity  is  cleaned  out  under  the  most  rigid  asepsis  and  the 
wound  closed,  preferably  with  two  layers  of  sutures,  covered  with 
a  dry  dressing,  and  allowed  to  heal  per  primam,  as.it  usually  will. 
Heck's  paste,  formalin  and  glycerin,  or  iodoform  and  glycerin, 
may  be  left  in  the  cavity  if  desired.  The  pus  may  reaccumulate 
and  require  repetition  of  the  treatment  a  second  or  even  a  third 
time.  If  the  line  of  suture  breaks  down  the  edges  should  be  cut 
away  and  rcsutured. 

Sinu-es  due  to  tuberculosis  (including  fistula  in  ano)  are  to  be 
treated  by  injection  of  bismuth  paste,  and  when  this  is  absorbed 
or  t  -capes  the  injection  should  be  repeated.  A  large  percentage 
of  them  are  cured  in  thi-  manner.  The  healing  of  locali/ed  tuber- 
culous abscesses,  such  as  ischiorectal  abscesses,  is  more'  likely  to 
occur  without  persistent  sinuses  if  the  paste  is  injected  soon  after 
incision. 


308 


PRINCIPLES   OF   SURGERY 


Tuberculosis  of  the  larynx  has  recently  been  reported  as  being 
amenable  to  cure  by  employment  of  the  very  simple  operation  of 
high  tracheotomy. 


Fig.  58. — Illustrating  position  employed  in  conjunction  with  insolation  in  cases 
of  Pott's  disease  (Straube). 


Fig.  59. — Case  of  Pott's  disease  prior  Fig.  60. — Same  case  restored 

to   treatment  by   position   and   insolation      by     position     and     insolation 
(Straube).  (Straube). 

Non-operative  Plans. — The  non-operative  means  for  treat- 
ment of  surgical  tuberculosis  are  numerous,  and  embrace  espe- 
cially the  methods  recommended  for  the  treatment  of  inflammatory 


TUBERCULOSIS  309 

processes  in  general.  The  most  important  in  this  connection  are: 
(1)  Rest,  either  by  refraining  from  muscular  exertion  on  the  part 
of  the  patient,  or  enforced  by  the  application  of  such  apparatus  as 
splints,  braces,  or  casts.  If  possible,  it  is  best  to  prevent  move- 
ment of  the  affected  part  without  completely  depriving  the  patient 
of  the  privilege  of  exercise  and  out-door  life.  (2)  Position  is 
important  in  those  cases  which  are  immobilized,  and  should  be 
such  that  the  patient's  comfort  may  be  least  disturbed,  and  the. 
1>«  rmanent  deformity,  if  deformity  must  come,  may  be  as  much 
as  possible  compatible  with  useful  function.  (3)  Bier's  hyperemic 
treatment  finds,  perhaps,  its  most  serviceable  field  hi  surgical 
tuberculosis,  and  is  produced  usually  by  the  passive  methods. 
\  Massage  is  of  especial  value,  and  is  to  be  applied  not  only  to 
tin-  diseased  part,  but  to  those  structures  whose  nutrition  is  in- 
terfered with  by  loss  of  function.  In  cases  of  sinuses  dependent 
on  tuberculous  processes  the  application  of  Bier's  method  by 
employment  of  tourniquets,  or  by  cupping  over  the  mouth  of  the 
sinus  and  the  injection  of  Beck's  paste,  or  the  employment  of  the 
hitter  plan  alone,  gives  most  satisfactory  results,  and  should  be 
undertaken  in  all  such  cases  before  resorting  to  more  active  meth- 
ods unless  the  indication  is  very  positive  against  it. 


CHAPTER    XVII 
SYPHILIS 

THIS  disease  is  one  of  such  varied  clinical  manifestation  that 
it  would  be  beyond  the  present  purpose  to  discuss  it  even  to  a 
moderate  extent.  The  subject  will,  therefore,  be  discussed  only 
to  such  an  extent  as  its  relation  to  surgery  and  its  differentia- 
tion from  other  surgical  lesions  demands. 

Etiology. — The  cause  of  syphilis  is  the  Spirochseta  pallida, 
discovered  by  Schaudinn  hi  1905.  This  minute  attenuated  spiril- 
lum is  discoverable  in  the  juices  of  syphilitic  tissues,  whether  the 
lesion  is  primary,  secondary,  or  tertiary,  abundantly  usually  hi 
the  former  two,  and  with  difficulty  hi  the*  last.  The  spirochete  is 
transmitted  by  mediate  or  immediate  contact,  usually  the  latter, 
and  that  during  the  sexual  act,  which  is  the  sole  reason  for  syphilis 
being  considered  a  venereal  disease.  Mediate  infections  and  those 
produced  by  other  than  sexual  contact  are  not  infrequent,  and 
physicians  suffer  more  from  infection  by  this  means,  especially 
from  needle  punctures,  cuts,  and  abrasions,  than  any  other  class. 
There  must  be  an  abrasion  of  the  mucous  or  cutaneous  epithe- 
lium before  it  is  possible  for  infection  to  occur. 

Pathology. — The  essential  lesion  of  syphilis  is  an  exudative 
and  proliferative  inflammation.  While  the  disease  is  capable  of 
unlimited  manifestations,  and  may  simulate  a  vast  number  of 
pathologic  and  clinical  conditions,  the  fundamental  fact  must  not 
be  lost  sight  of  that  an  infection  producing  an  inflammatory 
reaction  is  the  essential  underlying  factor.  Various  accidents 
and  complications  may  befall  these  syphilitic  lesions,  dependent 
somewhat  upon  the  site  of  their  formation;  thus,  ulceration, 
caseation,  sclerosis,  caries,  necrosis,  and  desquamation  of  epi- 
thelium may  occur  and  secondary  infections  may  take  place.  In 
the  earlier  stages  of  syphilis  the  tegumentary  structures  and 
lymph-nodes  are  chiefly  affected,  but,  as  the  disease  passes  into 
the  so-called  tertiary  stage,  there  is  no  structure  in  the  normal  body, 
from  the  nails  to  the  central  nervous  system,  secure  against  its 
ravages. 

The  period  of  incubation  varies  from  fourteen  to  forty  days, 
and  during  this  time  the  patient  shows  no  signs  of  infection.  The 
abrasion  which  served  as  the  atrium  heals  frequently  without 
being  discovered;  it  may  become  infected  with  ordinary  pyogenic 

310 


SYPHILIS  311 

bacteria  and  soon  heal,  or  it  becomes  infected  with  chancroidal 
bacteria,  and  develops  immediately  into  a  chancroid  which  may 
obscure  all  signs  of  a  beginning  syphilis. 

The  Stages  of  Syphilis. — The  course  of  syphilis  must  be 
recognized  as  a  continuous  one,  except  as  it  may  be  interrupted 
by  the  administration  of  antisyphilitic  remedies.  Three  stages 
an-  usually  recognized  and  described,  although  any  or  all  of  them 
may  fail  to  appear  or  escape  recognition;  and  it  is  precisely  these 
cases  running  an  atypic  course  that  have  caused  the  chief  difncul- 
ties  iii  the  diagnosis  of  late  syphilitic  lesions,  which  especially 
concern  the  surgeon.  The  history  of  a  definite  typic  course  of  the 
disease  is  of  very  positive  value;  its  absence  has  no  significance  in 
the  presence  of  questionable  late  manifestation. 

Primary  Stage. — The  primary  stage  of  syphilis  extends  from 
the  first  appearance  of  the  chancre  to  the  general  eruption,  which 
may  be  looked  for  at  an  average  of  six  weeks  from  the  date  of  the 
chancre,  but  varies  from  two  to  three  weeks,  or,  in  rare  cases,  even 
to  six  months.  This  is  known  as  the  period  of  secondary  incuba- 
tion. The  primary  stage  is  essentially  the  stage  of  the  local  sore 
a  i  1 1  1 1  he  lymphatic  involvement  attendant  upon  it.  This  lymphatic 
enlargement  is  always  in  a  correlated  group  of  lymph-nodes.  A 
single  node  may  enlarge;  a  single  large  one  and  several  smaller 
ones  may  be  observed,  or  several  nodes  of  about  the  same  size 
may  be  seen.  They  are  painless  if  due  to  pure  infection,  firm, 
di-crete,  non-adherent,  and  do  not  suppurate. 

The  chancre  may  be  obscured  by  mixed  infection  so  as  to  pre- 
sent no  characteristic  signs,  or  may  be  so  typic  as  to  leave  little  or 
no  room  for  a  mistaken  interpretation.  It  is  almost  invariably 
.-inide,  but  there  may  rarely  be  more  than  one  primary  sore,  due 
to  -imultaneous  infection  of  more  than  one  atrium.  The  chancre 
is  by  no  means  constantly  an  ulcer,  although  ulceration  is  the  rule. 
The  characteristic  feature  is  induration.  The  lesion  may  begin  as 
a  slight  abrasion  which  heals  and  breaks  down  again,  or  never 
heals  or  it  may  not  be  possible  to  recognize  .that  an  abrasion 
has  been  present  at  all,  and  the  first  evidence  may  be  a  watery 
blister.  Induration  may  be  felt  in  all  typic  chancres,  and  appears 
cither  as  a  roundish  lump  or  as  a  flattened,  nummulated  disk, 
the  thickness  of  which  varies  downward  to  that  of  a  sheet  of 
paper,  and  gives  to  the  palpating  fingers  the  impression  of  some- 
thing having  been  deposited  under  the  upper  layers  of  the  skin. 
Chancre-  are  painless,  do  not  discharge  abundantly  when  they 
ulcerate,  and  may  become  .-lowly  larger  and  stubbornly  refuse 
to  alter  their  si/e,  or  gradually  fade  away.  The  indurated  papular 
chancre  is  very  rare,  and  shows  no  break  in  the  epithelium;  the 
ulcerative  chancre  is  next  in  frequence,  and  involves  a  part  or  all 


312  PRINCIPLES   OF   SURGERY 

of  the  thickness  of  the  skin;  it  has  sloping  edges,  and  the  raw  base 
may  be  partially  or  completely  covered  with  a  grayish,  adherent 
pseudomembrane.  The  erosive  type  is  the  most  common,  and  is 
characterized  by  exfoliation  of  the  epidermis,  which  leaves  a 
glistening  surface  on  which  the  pseudomembrane  may  appear, 
and  surrounded  by  a  cyanotic  or  red  areola.  The  discharge  from 
the  last  two  types  named  is  serous  or  sanioserous.  The  shape  of 
chancres  in  general  is  approximately  round.  Chancres  do  not 
respond  to  any  local  non-syphilitic  treatment. 

Second  Stage. — The  second  stage  of  syphilis  begins  with  the 
manifestation  of  constitutional  infection,  and  is  characterized 
by  the  appearance  of  general  lesions  distributed  over  the  body, 
situated  superficially,  for  the  most  part  involving  especially  the 
skin,  the  mucous  membrane  and  lymph-nodes,  and  symmetric 
It  is  the  eruptive  stage  or  stage  of  constitutional  involvement, 
and  prior  to  the  recent  discovery  of  positive  diagnostic  methods 
it  was  waited  for  and  accepted  as  the  pathognomonic  sign  that 
a  primary  sore  was  truly  of  a  syphilitic  nature.  The  duration  of 
the  secondary  stage  is  not  nearly  so  well  marked  as  that  of  the 
primary,  for  while  the  appearance  of  a  syphilitic  eruption  marks 
definitely  the  end  of  the  first  stage,  only  its  appearance  and 
failure  to  reappear  indicate  the  end  of  the  second  stage.  It  is 
generally  accepted  that  the  second  stage  lasts  for  from  six  months 
to  two  years  or  longer.  This  stage  of  syphilis  may  fail  entirely 
to  appear  or  may  be  obscured  by  the  inadvertent  use  of  mer- 
cury during  the  first  stage;  however,  its  development  no  longer 
figures  extensively  in  the  diagnosis  of  syphilis,  and  it  is  now  inten- 
tionally prevented,  as  it  often  proves  of  great  embarrassment  to 
the  patient,  and  there  is  no  longer  necessity  to  lose  valuable  time 
in  treatment  by  permitting  the  disease  to  continue  unmolested  for 
several  months. 

The  eruption  of  syphilis  usually  appears  after  the  general 
lymph-node  involvement,  but  occasionally  precedes  it.  The  skin 
and  mucous  membrane  eruptions  are  called  syphilids  and  assume 
various  symmetric  manifestations.  They  are  produced  in  the 
upper  layers  of  the  skin  and  mucous  membrane,  and  appear  as 
hyperemic,  more  or  less  indurated  and  infiltrated  spots,  disap- 
pear during  the  course  of  the  disease  or  under  administration  of 
treatment,  and  leave  the  skin  normal.  The  later  secondary 
syphilids  may  involve  the  deeper  layers  of  the  tegumentary 
membranes  and  cause  destruction  of  tissue,  followed  by  cicatriza- 
tion. The  eruption  of  syphilis  may  resemble  or  simulate  that 
of  certain  eruptive  fevers  and  skin  diseases  so  closely  that  a 
differentiation  cannot  be  made  from  this  source.  They,  as  a  rule, 
require  several  days  to  mature,  but  occasionally  appear  and  disap- 


SYPHILIS 


313 


pear  with  such  rapidity  as  to  escape  the  patient's  observation. 
Like  the  chancre,  they  usually  produce  no  subjective  symptoms. 
There  is  a  tendency  for  secondary  (early)  syphilids  to  assume 
a  roundish  shape  and  for  groups  of  them  to  appear  in  circular 


Fig.  61. — Syphilis,  second  stage. 


arrangement  :m<l  symmetrically.  The  color  of  the  eruption  is  im- 
portant, reil  .it  first,  .-mil  later  assuming  the  so-called  copper 
color.  The  color  disappears  on  pressure  and  returns  on  its  release, 
as  in  all  hyperemic  conditions.  The  epidermis  over  the  surface 
of  the  syphilids  scales.  It  is  important,  from  a  diagnostic  stand- 


314  PRINCIPLES   OF   SURGERY 

point,  to  emphasize  that  the  syphilids  are  polymorphous,  unlike 
other  affections  of  the  skin,  so  that  one  type  of  syphilid  may  be 
found  on  one  part  and  another  elsewhere.  Hence,  papular, 
pustular,  and  macular  syphilids  may  all  appear  on  the  body  at 
one  time. 

Lesions  of  the  Mucous  Membrane. — One  of  the  most  constant 
manifestations  of  secondary  syphilis  is  the  mucous  patch  which 
appears  on  the  mucous  membrane  of  the  mouth,  particularly  on 
the  pillars  of  the  fauces,  about  the  tonsils,  on  the  tongue,  or  the 
soft  palate.  They  may  be  coincident  with  the  eruption,  but 
frequently  appear  before  it.  The  mucous  patch  is  not  an  ulcer, 
but  a  well-delimited  whitish  patch  not  raised  above  the  surround- 
ing surface,  and  looks  as  if  carbolic  acid  or  a  strong  solution  of  silver 
nitrate  had  been  applied  to  that  area.  Occasionally  an  edema- 
tous  erythema  appears  on  the  mucous  membrane  of  the  mouth 
and  pharynx.  These  lesions  are,  as  a  rule,  not  painful  unless  irri- 
tated by  substances  taken  into  the  mouth. 

Lymph-nodes  that  are  not  correlated  with  the  primary  lesion 
become  enlarged  during  the  secondary  stage,  usually,  as  already 
stated,  prior  to  the  appearance  of  the  eruption.  The  lymph- 
nodes  of  the  body  generally  are  enlarged  to  some  extent,  and,  if 
left  untreated,  some  of  them  may  become  greatly  enlarged,  but 
certain  nodes  and  groups  of  nodes  seem  to  be  subject  to  a  pre- 
dilection, namely,  the  epitrochlears  and  the  posterior  chain  of 
cervical  nodes,  and,  while  other  groups  may  be  distinctly  affected, 
the  presence  of  enlarged  epitrochlear  and  posterior  cervical 
nodes  is  rarely  found  from  other  causes  than  syphilis.  The  nodes 
are  painless,  not  tender,  show  no  surface  discoloration,  do  not 
suppurate,  remain  discrete,  do  not  infiltrate  the  periglandular  tis- 
sues, and  are,  therefore,  movable.  They  are  hard,  and  among  the 
last  of  the  secondary  lesions  to  respond  to  treatment.  Indeed, 
they  often  remain  somewhat  enlarged  even  after  an  apparent  cure 
has  been  produced. 

Fever. — There  is  usually  a  rise  of  temperature  at  the  begin- 
ning of  the  secondary  stage.  It  may  be  insignificant  and  of  short 
duration,  or  it  may  continue  until  the  patient  is  well  under  con- 
trol of  treatment.  The  temperature  does  not  often  rise  higher  than 
102°  F.,  but  occasionally  reaches  105°  F. 

It  is  accompanied  by  the  usual  febrile  syndrome  of  symptoms, 
and  may  simulate  malaria  or  typhoid,  and,  if  attended  with  an 
eruption  of  pustular  syphilids  and  osteocopic  pains,  may  be 
differentiated  from  small-pox  with  great .  difficulty.  The  tem- 
perature usually  returns  to  normal  when  the  eruption  appears, 
but  in  severe  cases  it  is  likely  to  continue  indefinitely  after  the 
eruption. 


SYPHILIS 


315 


Pain. — Although  the  syphilitic  is  free  from  pain  during  the 
fir-t  stage,  and  this  freedom  even  hi  the  chancre  is  a  very  suspi- 
cious omen,  the  second  stage  is  likely  to  be  attended  with  a  variety 
of  painful  sensations.  They  may  be  neuralgic  hi  character  and 
variable,  affecting  different  parts  at  successive  intervals,  but 
particularly  affecting  the  upper  part  of  the  back,  the  neck,  and 
shoulders.  Pain  may  be  especially  severe  hi  the  bones — osteo- 
copic  pains.  Headache  is  not  uncommon  at  this  stage.  If  the 
joints  are  painful  and  at  the  same  tune  swollen,  and  the  synovise 


Fig.  <>2. — Alopecia  arcata  in  a  syphilitic. 

arc  di-t  ended  with  fluid,  it  may  be  difficult,  in  the  absence  of  a 
< I. Unite  history,  to  eliminate  rheumatism.  While  the  above  are 
given  MS  points  especially  affected  by  pain  in  syphilis,  it  may 
appear  in  any  part  of  the  body  and  may  be  continuous  or  inter- 
mit lent,  ami  i-  usually  worse  at  night. 

Alopecia.— Fulling  of  the  hair  may  occur  at  any  time  during 
the  seroml  >t  a. ire  of  syphilis  and  may  affect  any  hairy  surface,  i>ut 
i-  r-perially  likely  to  involve  the  scalp  and  the  ryrl.mw-.  either 
of  which  may  escape.  The  fact  that  the  hair  rapidly  comes  out 
in  patches  (alopecia  areata)  is  very  su-picious  of  syphilis.  The 


316  PRINCIPLES   OF   SURGERY 

skin  remains  smooth  and  apparently  healthy  and  the  hair  returns 
under  antisyphilitic  treatment.  Alopecia  of  the  eyebrows  is  con- 
sidered by  high  authority  to  be  pathognomonic  of  syphilis. 

Tertiary  Syphilis. — Following  the  secondary  stage  the  tertiary 
syphilitic  lesions  may  occur  if  proper  treatment  has  not  been 
given,  occasionally  even  in  spite  of  proper  treatment.  It  is  the 
tertiary  stage  and  the  late  secondary  that  especially  concern  the 
surgeon,  the  stage  hi  which  ulcerative  or  gummatous  processes 
affect  not  only  the  superficial  but  the  deep  structures  of  the  body. 

Hereditary  Syphilis. — Syphilis  may  be  transmitted  from 
either  or  both  parents  to  the  child.  It  may  be  transmitted  for  a 
very  variable  period  after  its  contraction,  up  to  twenty  years  or 
more,  but  the  further  the  parent  from  the  primary  sore,  the  less 
likely  is  the  child  to  be  a  syphilitic  and  the  less  severe  its  disease. 
The  child  may  be  killed  in  the  early  months  of  pregnancy  by 
syphilis  of  the  parent,  and  this  is  a  frequent  cause  of  repeated  and 
often  unexplainable  abortions  and  miscarriages;  it  may  go  to 
term  almost  and  die,  it  may  die  at  or  soon  after  birth  at  term,  or 
it  may  be  born  healthy  to  all  appearances  and  develop  syphilis 
within  a  year  or  two,  which  is  the  rule,  or  belong  to  the  type  known 
as  late  hereditary  syphilis,  and  not  manifest  its  disease  before  the 
age  of  puberty. 

There  is  no  primary  stage  of  hereditary  syphilis,  all  the  lesions 
appearing  as  secondary  or  tertiary,  and  these  appear  side  by' side. 

Diagnosis  of  Syphilis. — We  are  concerned  here  not  so  much 
with  the  diagnosis  of  syphilis  as  such,  when  it  runs  a  typic  course, 
when  the  disease  is  actively  present,  but  with  the  recognition  of 
it  when  the  active  stages  have  become  history,  often  enough  con- 
cealed history,  and  when  only  vestiges  are  left  here  and  there  to 
point  us  to  the  true  nature  of  the  condition  that  has  caused  a  con- 
sultation with  the  surgeon.  If  the  history  can  be  given  by  a 
former  diagnosis  at  competent  hands,  if  a  history  of  the  primary 
sore  be  obtained,  together  with  the  local  lymphatic  involvement 
and  later  development  of  secondary  symptoms  and  signs,  it  may  be 
unnecessary  to  go  further.  If  it  is  the  case  of  a  child,  consulta- 
tion privately  with  the  father  may  clear  up  the  diagnosis  entirely. 
But  it  must  not  be  forgotten  that  a  great  many  have  syphilis, 
acquired  or  hereditary,  who  know  nothing  of  the  fact.  Search  may 
be  made  for  the  presence  of  scars,  especially  pigmented  scars  on 
the  body,  but  the  average  case  does  not  show  them.  Scars  of  the 
mucous  membrane,  of  the  mouth,  spots  of  alopecia?  on  the  scalp 
or  eyebrows,  evidence  of  bone  destruction,  such  as  a  flattened 
nose,  a  perforated  nasal  septum  or  perforation  of  the  hard  palate, 
enlargement  of  the  epitrochlear,  posterior  cervical  or  popliteal 
lymph-nodes,  an  unexplainable  headache  or  neuralgia,  or  involve- 


SYPHILIS  317 

ment  of  the  central  nervous  system,  as  in  locomotor  ataxia,  may 
lend  a  clue  to  the  real  status.  If  such  evidences  cannot  be  found, 
then  resort  must  be  had  to  one  of  two  courses,  one  slow,  the  other 
rapid.  First,  a  course  of  treatment  for  syphilis  may  be  insti- 
tuted, and  if  no  response  is  observed  it  may  sometimes  be  ac- 
cepted as  positive  evidence;  but  the  demand  is  frequently  too 
urgent  to  dally  with  so  slow  a  method,  and,  besides,  we  know  that 
certain  of  the  later  lesions  are  uninfluenced  by  such  treatment,  or 
respond  so  slowly  that  no  signs  of  improvement  can  be  had  within 
a  safe  limit.  The  second  and  most  satisfactory  plan  is  to  make  a 
test  of  the  blood  for  Wassermann's  or  Noguchi's  reaction,  which  not 
only  gives  evidence  of  the  presence  of  syphilitic  infection,  but  indi- 
cates the  intensity  of  the  infection.  Syphilitics  that  have  been 
and  remained  cured  clinically  for  long  periods  almost  invariably 
respond  to  this  test,  which  can  be  accepted  as  reacting  in  between 
95  and  100  per  cent,  of  the  cases. 

Surgical  Syphilitic  Lesions. — Comparatively  few  of  the  changes 
produced  by  syphilis  are  of  direct  concern  to  the  surgeon.  They 
are  especially  syphilitic  ulcers,  syphilis  of  the  bone,  of  the  joints 
and  bursse,  of  the  muscles,  of  the  tendon  sheaths,  of  the  viscera, 
and,  for  the  purpose  of  differential  diagnosis,  syphilis  of  the  lym- 
phatic vessels  and  nodes.  It  may  be  impressed  that  the  most  im- 
portant lesions  of  syphilis,  from  the  surgeon's  standpoint,  are 
ulcers  and  gummata,  wherever  situated,  and  syphilis  of  bone. 

Gummata. — Before  taking  up  surgical  syphilitic  lesions  in 
detail  it  is  necessary  to  consider  gummatous  formations  in  their 
relation  not  only  to  these  surgical  lesions,  but  as  well  to  various 
other  lesions  with  which  they  are  frequently  confused. 

The  nature  and  structure  of  gummata  have  already  been 
discussed  sufficiently  for  our  purpose.  Gummata  may  form 
during  the  secondary  or  tertiary  stage  of  syphilis,  usually  the 
latter.  When  they  appear  early  hi  the  secondary  stage  they 
indicate  a  severe  infection.  While  they  develop  by  predilection 
at  certain  points  and  in  certain  tissues  or  organs,  there  is  no  struc- 
ture in  the  body  that  can  be  said  to  be  immune.  Hence,  great 
difficult ies  necessarily  arise  when  attempt  is  made  to  differentiate 
them  from  tumors,  benign  and  malignant,  and  from  other  granu- 
lomata.  The  frequent  absence  of  syphilitic  history  is  confusing, 
but  the  admission  of  such  a  history  does  not  justify  a  hasty  con- 
clusion that  the  present  lesion  is  a  gumma  and  not  a  tumor. 

Gross  Appearance. — Gummata  are  more  or  less  round  masses 
of  new-formed  tissue,  and  are,  as  a  rule,  non-encapsulated.  The 
si/.e  varies  from  that  of  a  pea  to  that  of  a  large  orange,  although 
very  large  gummata  are  very  rare.  On  section  they  appear  as  a 
grayish-red,  gelatinous  substance,  which  in  the  older  central  por- 


318  PRINCIPLES   OF   SURGERY 

tion  may  be  soft  and  whitish.  They  undergo  caseation  and  de- 
velop fibrinous  tissue  in  their  substance  at  the  same  time,  but  the 
caseation  does  not  involve  the  whole  mass,  as  a  rule,  as  it  does  in 
tubercular  granulomata,  so  that  the  zone  of  grayish  red  usually 
surrounds  the  caseating  central  portion.  Microscopically  the 
non-caseated  portions  show  small  spindle  cells  and  a  variety  of 
round  cells.  One  sees  isolated  giant  cells  occasionally.  The 
caseating  portion  shows  fatty  granular  cells,  stunted  nuclei,  and 
fragments  of  nuclei. 

Diagnosis. — Clinically  it  is  difficult,  frequently  impossible,  to 
differentiate  gummata  from  tubercle  or  sarcoma,  less  frequently 
from  benign  tumors  and  from  actinomycosis.  When  ulceration 
has  taken  place  confusion  arises  between  gumma  and  epithelioma. 
Hence,  the  microscope,  itself  often  enough  unreliable,  may  be  neces- 
sary to  make  a  differentiation;  the  Wassermann  test  and  search 
for  tubercle  bacilli  by  staining  or  by  inoculation  will,  of  course, 
often  be  of  service. 

Syphilitic  Ulcers. — From  the  appearance  of  the  first  sore  to  the 
end  of  his  life  the  syphilitic  may  be  subject  to  ulceration,  except 
where  adequate  treatment  has  been  done,  and  satisfactory  treat- 
ment of  the  ulcer  can  be  made  only  when  its  true  nature  is  recog- 
nized. Chancre  has  already  been  sufficiently  discussed;  it  is,  there- 
fore, necessary  here  to  discuss  only  the  ulcers  arising  during  the 
secondary  and  tertiary  periods. 

Ulceration  in  syphilis  may  be  due  either  to  the  breaking 
down  of  a  gumma  or  an  infiltrated  tissue,  such  as  condylomata 
about  the  anus  or  vulva,  especially  in  filthy  individuals,  or  to  the 
predisposing  influence  of  nutritional  disturbances,  as  hi  syphilitic 
arteriosclerosis  and  endarteritis.  We  are  concerned  here  about 
the  former.  When  gummata  form  in  or  under  the  skin  or  mucous 
membrane  and  undergo  caseation  they  appear  soft  at  a  point  on 
the  surface,  rupture,  discharge  a  gelatinous,  perhaps  a  purulent, 
mass,  and  form  a  deep  punched-out  or  undermined  ulcer,  which 
is  surrounded  by  the  indurated  remains  of  the  gumma  which  have 
escaped  degeneration.  The  gumma  may  grow  slowly  and  in  a 
very  brief  time  undergo  the  changes  above  given;  if  it  has  caused 
confusion  as  to  its  nature,  such  a  course  will  indicate  its  true 
nature.  Gummata  of  the  skin  and  mucous  membrane  may  be 
single  or  multiple  and  are  often  grouped,  so  that  when  ulceration 
occurs  they  may  destroy  the  intervening  tissues  and  cause  one 
large  ulcer,  as  the  ulcers  are  prone  to  enlarge  once  they  are  es- 
tablished. After  all  the  diseased  tissue  has  disappeared,  cicatri- 
zation takes  place  slowly  and  healing  may  thus  occur.  Some  of 
these  ulcers,  however,  especially  on  the  mucous  membrane,  spread 
on  one  side  while  they  are  healing  on  the  other  (serpiginous  ul- 


SYPHILIS  319 

cers),  and  when  they  appear  in  the  lumen  of  the  intestine  are  often 
the  cause  of  stricture.  Syphilitic  ulcers  are  sometimes  phage- 
denic. 

Sites  of  Predilection. — The  sites  of  predilection  of  syphilitic 
ulcers  are  practically  the  same  as  those  for  gummata  of  the  skin 
and  mucous  membrane.  The  middle  of  the  forehead  is  a  frequent 
site  of  syphilitic  ulcer,  and  the  bone  beneath  the  ulcer's  base  may 
become  involved  and  destroyed  through  the  thickness  of  the 
cranium  and  the  dura  be  exposed.  In  the  lower  extremities  gum- 
mata are  frequently  observed;  they  appear  more  frequently 
in  the  upper  and  lower  thirds  of  the  leg  and  on  the  external  and 
anterior  surfaces.  Here  they  are  usually  multiple,  and  are  one 
of  the  most  obstinate  types  of  chronic  ulcer  of  the  leg.  Other 
sites  are  the  forearm,  arm,  sternal  and  clavicular  regions,  the 
male  genitalia,  and  the  external  female  genitalia. 

On  the  mucous  membrane  they  are  found  most  frequently  in 
the  mouth  and  nose,  especially  on  the  hard  palate  and  on  the  nasal 
septum,  hi  each  of  which  they  are  very  prone  to  perforate  the  bone 
or  cartilage,  causing  a  communication,  in  the  one  instance,  be- 
tween the  mouth  and  the  nose,  and  hi  the  other  between  the  two 
sides  of  the  nose.  These  openings  will  rarely  be  seen  except  as  the 
result  of  syphilis.  In  the  pharynx  gummata  appear  usually  on 
the  posterior  wall  and  follow  the  usual  course  to  ulceration.  If 
they  develop  sufficiently  low  their  healing  is  very  likely  to  result 
in  stricture  at  the  beginning  of  the  esophagus.  A  similar  mis- 
fortune may  befall  the  Eustachian  tubes  from  cicatrization  of 
syphilitic  ulcers  of  the  tonsils,  producing  permanent  disturbance 
of  hearing.  The  stomach  and  intestines  may  be  involved,  and  in 
the  -mall  intestine  healing  may  produce  sufficient  constriction  to 
cause  chronic  obstruction.  In  the  anus  and  rectum  we  have  a 
very  common  site  of  syphilitic  ulceration,  and  the  resultant  stric- 
ture of  the  rectum  or  anus  is  very  suggestive  of  syphilis,  pro- 
vide* 1  it  is  not  congenital  or  malignant. 

Lymphatics  and  Lymph-nodes. — Lymphangitis  may  appear  in 
the  iOnn  of  a  hard  cord  leading  along  the  dorsum  of  the  penis, 
beneath  the  skin,  during  the  presence  of  the  chancre.  There 
may  be  several  of  these  cords.  They  are  painless,  and  do  not  show 
the  local  signs  of  inflammation  except  swelling  and  induration. 
The  appearance  and  location  of  the  primary  lymph-node  involve- 
ment and  that  occurring  in  the  secondary  and  tertiary  stages  of 
acquired  syphilis  have  been  discussed  already.  It  only  remains 
\  a  word  about  the  lymphadenitis  of  hereditary  syphilis. 
The  same  rules  hold  for  these  as  for  those  of  acquired  syphilis, 
except  that  the  >ite<  of  predilection  are  very  ditTerent ;  in  hered- 
itary .-yphilis  the  nodes  involved  are  the  same  as  those  affected 


320  PRINCIPLES   OF   SURGERY 

by  tuberculosis,  namely,  the  anterior  cervical  chains,  and  they 
cannot,  by  ordinary  clinical  methods,  be  distinguished  from 
tubercular  nodes.  In  cases  of  chancre  of  the  mouth,  nose,  or 
fauces  the  anterior  chain  or  the  submaxillary  nodes  on  one  side 
will  be  affected. 

Syphilitic  nodes  of  the  neck,  secondary  and  tertiary,  bear  no 
relation  to  pathology  in  the  nose,  mouth,  or  pharynx,  as  tuber- 
cular nodes  do.  The  nodes  in  syphilis  are  bilateral;  hi  tuberculosis 
they  may  or  may  not  be.  In  syphilis  they  remain  discrete  and 
movable;  in  tuberculosis  they  frequently  are  fixed  and  so  agglu- 
tinated into  one  mass  that  separate  nodes  are  no  longer  distin- 
guishable. When  syphilitic  nodes  ulcerate  they  produce,  as  a 
rule,  larger  ulcers  with  more  tendency  to  slough,  while  ruptured 
suppurative  tubercular  nodes  produce  discharging  sinuses.  The 
therapeutic  test  and  Wassermann's  reaction  show  syphilis,  while 
tubercular  infection  may  be  demonstrated  by  guinea-pig  inocula- 
tion. 

Syphilis  of  Bone. — Acquired  and  hereditary  syphilis  of  the 
bones  will  be  dealt  with  separately,  with  the  understanding  that 
late  hereditary  syphilis — i.  e.,  that  producing  lesions  at  or  after 
puberty — is  practically  identical  with  the  former. 

The  changes  produced  in  the  osseous  system  by  syphilis  are, 
first,  caries  and  necrosis  due  to  destruction  of  bone  tissue  by  the 
appearance  of  gummata  of  the  bone  or  periosteum.  Second,  the 
building  of  new  bone  tissue  which  may  lead  to  bone  hypertrophy, 
and  to  ossification  of  cicatrices  which  have  formed  as  the  result  of 
injury. 

Gummatous  foci  appear  usually  in  connection  with  the  perios- 
teum and  the  open  spaces  of  the  bony  substance.  They  are  rarely 
seen  originating  in  the  medullary  canal.  These  gummata  vary  in 
size,  up  to  that  of  a  lemon  or  small  orange,  and  can  with  the 
greatest  difficulty  be  distinguished  clinically,  and  often  enough 
microscopically,  from  sarcomata.  Unlike  the  lesions  elsewhere, 
they  are  very  painful  or  sensitive.  They  may  appear  as  rounded 
nodules  or  may  become  fusiform  along  the  length  of  the  bone. 
When  incised  they  prove  to  be  made  up  of  a  soft,  sometimes  almost 
fluid,  substance  which  has  a  poor  supply  of  cells,  round  and 
spindle  shaped;  if  the  small  round  cells  are  very  abundant  the 
contents  may  appear  very  similar  to  a  whitish  pus.  In  still  other 
instances  the  substance  resembles  granulation  tissue  and  tends 
to  form  scar  tissue.  Caseation  follows  and  produces  the  usual 
changes  in  the  gummatous  tissue. 

This  gummatous  development  takes  place  at  the  expense  of 
bone  tissue,  especially  if  endarteritis  and  periarteritis  are  present, 
and  a  carious  process  develops  which  produces  destruction  of 


SYPHILIS 


321 


large  portions  of  bone  tissue  with  no  evidence  of  suppuration 
except  where  secondary  infection  occurs.  This  is  known  as 
syphilitic  or  gummatous  caries.  The  skin  over  the  defects,  even 
when  the  bone  lies  close  underneath  it,  may  remain  intact  and 
even  settle  down  into  the  pockets  made  by  the  bone  destruction 
without  becoming  reddened  or  swollen.  If  the  gummata  sur- 
round large  portions  of  bone  the  whole  mass  may  become  necrotic 
and  become  separated  from  its  attachments  as  a  sequestrum. 
This  is  a  syphilitic  or  gummatous  necrosis.  It  is  superfluous  to 
say  that  when  an  opening  forms 
through  the  skin  secondary  in- 
fection is  established  and  a  pur- 
ulent discharge  occurs.  It  is  ac- 
cidental and  is  no  essential  part 
of  the  syphilitic  process.  The 
tibia,  cranium,  and  clavicle  are 
most  frequently  affected. 

Diagnosis. — The  differentia- 
tion of  these  processes  from 
similar  ones  caused  by  other 
conditions,  especially  tuberculo- 
sis and  sarcoma,  is  often  diffi- 
cult, and  resort  must  be  had 
then  to  the  usual  methods  of 
differentiation.  Syphilitic  bone 
lesions  are  painful,  and  the  pain 
is  intensified  during  the  hours  of 
sleep. 

Syphilitic  Bone  Hypertrophy. 
These  processes  are  the  result 
of  stimulation  to  bone  develop- 
ment by  syphilitic  inflammation 
of  the  osteoplastic  tissue.  They 
may  appear  alone — i.  e.,  unac- 
companied by  gummatous  oste- 
it  is  or  periostitis — when  new  bone 

formation  is  the  simple  result;  or  in  connection  with  gummatous 
inflammation,  when  both  processes  work  side  by  side,  one  build- 
ing up  while  the  other  tears  down.  So  an  enlargement  or  nodules 
appear;  the  periphery  may  become  greater  while  rarefaction  is 
taking  place  within,  or  the  IK  me  may  increase  in  size,  become 
rarefied  in  spots,  and  have  openings  develop  at  many  points 
leading  from  the  surface  to  the  medullary  canal.  The  perios- 
teum may  lie  increased  enormously  in  thickness,  more  than  in 
any  other  disease. 


Fig.    63. — Synhilitic    peri' 
fibula  and  tibia. 


iost  it  is    of 


-.-1 


322  PRINCIPLES   OF   SURGERY 

Hereditary  Bone  Syphilis. — As  already  stated,  this  is  meant 
to  embrace  only  those  lesions  which  occur  from  birth  to  puberty. 
There  are  two  forms  of  early  hereditary  bone  syphilis — namely, 
syphilitic  osteochondritis  and  periostitis  ossificans;  the  former  is 
much  more  common. 

Syphilitic  osteochondritis  affects  chiefly  the  tissues  adjacent 
to  the  epiphyseal  lines,  especially  of  the  femur,  tibia  and  fibula, 
humerus  and  ribs,  sometimes  of  other  bones.  One  or  several  bones 
may  be  attacked  at  one  time.  The  affection  varies  from  an  in- 
significant, often  microscopic,  change  to  marked  deformities  of 
the  bone,  producing  clinical  signs  and  symptoms,  and  responsible 
for  lesions  or  serious  accidents  to  the  bones  affected.  The  lesion 
consists  essentially  in  the  deposit  of  lime-salts  hi  the  affected 
tissue;  the  normal  epiphyseal  line  and  the  whitish  mass  extend  at 
places  into  the  adjacent  cartilage.  This  is  the  simplest  macro- 
scopic form.  As  the  process  advances-  the  chalk  zone  becomes 
much  broader,  is  still  irregular,  and  friable;  hi  this  stage  the  car- 
tilage may  become  very  much  hypertrophied,  as  in  rickets,  with 
the  difference,  however,  that  in  syphilis  there  is  an  excess  of 
lime-salts  deposited,  while  in  rickets  the  lime  content  is  dimin- 
ished. In  still  more  severe  forms  the  epiphysis  may  be  very  much 
enlarged  and  thickened.  Sometimes  softening  occurs  between 
the  bone  and  the  chalky  deposit,  due  to  an  osteomyelitic  focus. 
The  trabeculae  of  the  bone  lose  their  regularity,  and  no  longer  show 
their  normal  position  of  lying  in  the  axis  of  the  bone  and  parallel 
with  each  other.  The  presence  of  the  brittle,  chalky  deposit 
renders  the  epiphyseal  attachment  far  less  firm  than  normal,  and 
thus  easily  subject  to  separation.  Epiphyseal  separation,  occur- 
ring as  it  sometimes  does  in  healthy  bones,  shows  a  smooth  line 
of  separation;  but  in  syphilitic  chondritis  the  line  of  fracture  is 
"uneven,  nodulated  or  undulated,  and  friable."  Occasionally  in 
very  severe  cases  the  epiphyses  are  spontaneously  separated,  due 
to  the  absorptive  influence  of  granulation  tissue.  This  epiph- 
yseal separation  is  the  cause  of  pseudoparalysis  (Kaufmann). 
Variations  in  the  length  of  the  bone  may  occur,  so  that  the  bone 
that  has  suffered  from  osteochondritis  may  be  either  shorter  or 
longer  than  normal.  Occasionally  gummata  form  in  hereditary 
syphilis  of  bone. 

The  bones  of  the  skull  especially  are  affected  by  proliferative 
lesions,  and  deformity  of  the  cranium  or  microcephalus  may 
result.  The  most  usual  deformity  is  lack  of  symmetry.  Nodules 
sometimes  form  on  the  parietal  and  frontal  eminences  (Parrot's 
nodes). 

Syphilitic  Dactylitis. — The  bone  lesion  known  as  syphilitic 
dactylitis  affects  either  toes  or  fingers,  preferably  the  latter. 


SYPHILIS 


323 


It  occurs  usually  in  infants,  and  appears  as  an  infiltration  in  the 
dipt,  which  may  originate  either  in  the  soft  tissues  of  the  digit, 


Fig.  64. — Syphilitic  vault  of  cranium. 


Fin.  t»o. — Hand  of  patient.     Syphilis,  thini  st:mr. 


324  PRINCIPLES   OF   SURGERY 

in  the  bone,  or  its  coverings.  The  swelling  is  not  clearly  denned, 
has  a  cyanotic  hue,  and  assumes  more  or  less  a  spindle  shape. 
/There  may  be  several  such  lesions.  They  produce  little  or  no 
pain,  and  unless  their  true  nature  is  recognized  and  they  are 
properly  treated  they  undergo  degeneration  and  discharge  their 
contents.  They  may  destroy  the  bone  tissue,  causing  a  dis- 
turbance of  nutrition  and  an  underdevelopment  of  the  digit. 

Syphilis  of  Joints. — The  joints  are  affected  in  various  ways 
by  syphilis,  so  that  any  lesion  produced  by  other  causes  may  be  so 
closely  simulated  as  to  render  differentiation  difficult. 

Pain. — There  may  be  no  discoverable  swelling,  no  subjective 
symptom,  no  objective  sign  of  disease  in  the  joints  other  than 
pain,  which  is  a  common  symptom  of  secondary  syphilis,  and 
resembles  the  osteocopic  pains  in  its  behavior. 


Fig.  66. — Mandible,  the  body  of  which  has  been  almost  completely  destroyed 

by  necrosis. 

Synovitis. — This  lesion  may  appear  during  the  early  secondary 
stage,  but  usually  appears  later,  sometimes  even  as  a  late  tertiary 
symptom.  It  may  affect  a  single  joint,  preferably  the  knee,  or 
several  joints,  when,  if  acute,  it  can  with  difficulty  be  distin- 
guished from  acute  articular  rheumatism,  or  it  may  be  sym- 
metric. The  condition  is  either  acute  or  chronic.  The  chronic 
form  is  at  times  very  persistent  and  is  a  monarticular  affection. 
Sometimes  in  the  poly  articular  form  all  the  joints  respond  to 
treatment  but  one,  which  persists  stubbornly  and  indefinitely. 
There  may  be  little  effusion  into  the  synovial  cavity,  or  a  large 
effusion  may  be  poured  out;  the  synovise  are  thickened,  and 
gummata  are  found  in  these  membranes  or  in  the  articular  ends 
of  the  bones  and  in  the  ligaments.  Degeneration  of  these  gum- 
mata may  produce  a  distinct  arthritis.  Healing  of  such  a  process 


SYPHILIS  325 

may  cause  marked  interference  with  function,  or  the  joint  may 
become  useless  on  account  of  the  formation  of  osteophytes. 
Syphilitic  synovitis  is  usually  painless  or  but  little  painful,  al- 
though in  some  instances  pain  may  be  marked.  If  destruction 
of  the  articular  cartilages  takes  place,  crepitation  may  be  elicited 
by  passive  motion.  The  presence  of  painless  synovitis,  with  con- 
siderable swelling  and  a  surprising  want  of  disturbance  of  func- 
tion, should  cause  suspicion  of  syphilis,  or  the  presence  of  the 
condition  hi  several  joints,  with  little  or  no  constitutional  symp- 
toms and  absence  of  pain  and  unpaired  function,  should  likewise 
lead  to  this  conclusion. 

Syphilis  of  Bursse. — The  bursae,  being  structurally  and  func- 
iiunally  similar  to  the  synoviae,  are  similarly  affected  by  syphilis. 
The  bursse  of  the  knee  are  especially  affected.  The  usual  form  of 
this  condition  is  an  acute  bursitis  coming  up  hi  the  earlier  part  of 
the  second  stage.  There  may  be  a  considerable  accumulation  of 
fluid  in  the  sacs,  accompanied  by  some  pain  and  tenderness. 
As  a  rule  it  subsides  promptly.  The  condition  is  very  rare. 

Gummatous  bursitis,  too,  may  appear,  affecting  especially  the 
prepatellar  bursa.  It  is  painless,  and  is  characterized  by  the 
presence  of  nodules  and  later  of  fluid,  due  to  degeneration.  It 
is  at  first  hard  and  later  fluctuant  and  is  apt  to  rupture  on  the 
surface.  Other  bursse  about  the  knee  may  be  similarly  affected, 
and  when  degeneration  occurs  may  rupture  into  the  joint  or  on 
the  cutaneous  surface. 

The  tendon-sheaths  are  at  times  inflamed  during  the  second 
stage  (syphilitic  tenosynovitis).  The  signs  and  symptoms  do  not 
differ 'from  ordinary  inflammation  of  these  structures.  The  gum- 
matous  form  of  tenosynovitis  occurs  later,  and  usually  in  con- 
junction with  syphilis  of  an  adjacent  bone.  Its  recognition  is 
more  difficult,  and  depends  largely  on  collateral  evidence  of 
syphilis. 

Syphilis  of  the  Muscles. — Aside  from  the  myalgia  associated 
with  tin  M-c.imlary  stage  of  syphilis  there  are  two  distinct  surgical 
lesions — myositis  and  gummatous  infiltration. 

Myositis. — This  comes  up  during  the  secondary  period  as  an 
acute  or  subacute  inflammation.  Its  development  is  accompanied 
with  contract urc,  which  may  be  sudden  or  gradual.  It  is  a  very 
ran-  condition  and  affects  certain  muscles  by  preference,  namely, 
the  lii-vp-.  hiimrri  and  occasionally  other  muscles,  especially 
flexors.  There  is,  as  a  rule,  little  pain  except  on  attempted  passive 
motion,  which  produces  violent  pain.  The  muscle  is  slightly 
harder  than  normal  and  shows  no  electric  response. 

The  chronic  form  of  syphilitic  myositis  occurs  late  in  the  ter- 
tiary stage,  possibly  as  long  as  twenty  to  thirty  years  after  infec- 


326  PRINCIPLES   OF   SURGERY 

tion.  It  is  a  diffuse  inflammation,  and  is  prone  to  result  in  new 
tissue  formation,  causing  atrophy  of  the  muscular  tissue  and 
hopelessly  permanent  contractures.  The  biceps  humeri  and 
external  sphincter  ani  are  most  frequently  affected,  sometimes 
also  the  sternomastoid,  the  masseter,  muscles  of  the  arm,  and  the 
sural  muscles.  Pain  is  absent  or  insignificant,  except  when  motion 
is  attempted.  The  usual  signs  of  inflammation  are  wanting,  and 
only  pain,  as  above  mentioned,  swelling  at  the  beginning  of  the 
process,  induration,  and  loss  of  function  are  to  be  found.  As  the 
process  progresses,  atrophy  and  cicatrization  occur.  Rarely  it 
assumes  the  nature  of  myositis  ossificans. 

Gummatous  myositis  is  frequently  indistinguishable  clinically 
from  the  above,  owing  to  the  presence  of  great  numbers  of  minute 
gummata  distributed  throughout  the  muscular  substance.  When 
the  nodules  are  palpable,  they  appear  either  as  a  single  mass,  which 
may  reach  a  large  size,  that  of  an  orange,  or  as  several  nodules 
distributed  throughout  the  substance  of  the  muscle.  The  sterno- 
mastoid is  usually  attacked;  the  pectoralis  major,  trapezius, 
biceps  humeri,  glutei,  and  the  muscles  of  the  tongue  are  other 
favorite  sites.  Gummata  in  muscles  appear  late  in  the  tertiary 
stage,  except  in  the  more  malignant  types  of  syphilis.  They 
usually  appear  in  the  belly  of  the  muscle  or  at  the  end  of  inser- 
tion. They  are  slowly  growing  masses  and  are  not  painful.  They 
may  disappear  under  treatment,  or  soften  and  rupture  on  the 
surface,  discharging  yellow  pus  or  sometimes  a  steel-gray  pus. 
The  resulting  ulcer  or  sinus  is  slow  to  heal.  The  disappearance 
of  gummata  leaves  a  cicatrix  which  cripples  the  muscle  to  the 
extent  of  involvement.  Therefore,  when  they  are  numerous,  per- 
manent loss  of  function  may  follow,  and  the  remains  of  the  muscle 
appears  as  an  atrophied  fibrous  band. 

Gummata  of  muscle  are  readily  confused  with  tumors,  espe- 
cially with  sarcoma  if  the  gumma  is  single  and  large;  with  epi- 
thelioma,  if  it  is  situated  on  the  tongue  and  ulcerative,  and  with 
parasitic  cysts,  especially  cysticercus.  The  appearance  will 
often  resemble  actinomyces  when  the  masseter  muscle  is  in- 
volved, but  the  presence  of  the  fibrous  ridge,  if,  indeed,  it  be 
present,  leading  from  the  atrium  is  characteristic  of  the  latter. 
The  Wassermann  reaction  is  a  most  valuable  differential  means, 
but  it  must  not  be  forgotten  that  a  one-time  syphilitic  can  acquire 
any  of  these  lesions.  Hence,  the  clinical  evidence  alone  is  not  to 
be  relied  upon;  a  microscopic  examination  should  always  be  made 
before  radical  steps  are  undertaken. 

Syphilis  of  the  Abdominal  Viscera. — Fortunately  for  the  sur- 
gical diagnostician  syphilis  of  the  viscera  in  general  is  quite  fre- 
quently accompanied  by  syphilis  of  bone.  Only  those  phases  of 


SYPHILIS  327 

visceral  syphilis  that  are  of  especial  surgical  importance,  either 
from  the  standpoint  of  diagnosis  or  treatment,  will  be  discussed 
in  this  text. 

Liver. — More  frequently  than  any  other  intra-abdominal 
viscus  the  liver  is  affected.  Affection  of  this  organ  rarely  occurs 
during  the  secondary  stage,  but  very  frequently,  though  usually 
late,  in  the  tertiary  period.  The  type  of  congenital  syphilis  of  the 
liver  known  as  interstitial  syphilitic  hepatitis  does  not  concern  us 
here.  The  gummatous  congenital  type  is  practically  identical 
with  the  acquired  form. 

Syphilis  of  the  liver  may  be  either  of  an  inflammatory  or  a 
gummatous  type  or  the  two  may  be  combined. 

The  inflammatory  or  cirrhotic  type  is  the  result  of  an  inflam- 
mation developing  at  various  foci  throughout  the  liver,  the  ap- 
pearance of  a  consequent  new-tissue  formation,  the  cicatrization 
of  which  produces  the  various  local  changes  and  the  collateral 
symptoms.  The  cicatricial  tissue  develops  in  the  form  of  septa 
•  lipping  into  the  liver  substance  from  the  capsule  of  Glisson,  and 
the  contraction  of  this  tissue  produces  hi  the  liver  the  peculiar 
contour  that  has  given  it  the  name  of  hepar  lobatum.  The  liver 
is  often  so  distorted  that  it  shows  no  resemblance  to  the  normal ; 
it  may  be  contracted  into  a  much  smaller  size  than  is  requisite 
for  normal  function,  or  it  may  be  further  altered,  either  by  com- 
pensatory hypertrophy  or  by  amyloid  change.  The  deepest 
retractions  are  usually  in  the  neighborhood  of  the  suspensory 
ligament.  Adhesions  may  occur  between  the  liver  surface  and  the 
surrounding  structures;  the  capsule  is  very  much  thickened,  and 
the  size  of  the  liver  may  ultimately  be  reduced  to  the  size  of  a 
fist,  although  at  the  beginning  slight  enlargement  may  have  oc- 
curred. The  whole  or  a  part  of  the  liver  may  be  lobulated.  The 
spleen  may  be  considerably  enlarged  in  cases  of  hepar  lobatum. 

Symptoms. — Syphilitic  cirrhosis  may  be  symptomless.  When 
symptoms  are  present  they  are  referable  especially  to  the  digest- 
ive tract.  The  presence  of  a  lobulated  liver,  with  reduction  in 
>i/e  at  one  point  and  enlargement  at  another,  with  evidence  of 
adhesions,  should  arouse  grave  suspicion.  The  patient  may  com- 
plain of  diiie-tive  di>turl)ances.  diarrhea,  vomiting  of  blood,  as- 
cites,  and  edema  of  the  lower  extremities  or  varicosis. 

A-i-ites  comes  up  slowly,  but  recurs  rapidly  after  paracentesis. 
Allmminuria  may  be  an  associate  symptom.  Icterus  is  rare 
This  condition  may  be  confused  with  cancer  or  sarcoma  of  the 
liver  and  with  cirrhosis  from  other  causes.  The  slow  develop- 
ment of  the  condition,  variation  in  the  -i/e  of  the  liver,  the  ab- 
sence of  other  tubercular  foci,  and  positive  \\assermann  reaction 
or  a  history  of  syphilis  will  usually  make  the  diagnosis. 


328  PRINCIPLES    OF   SURGERY 

In  case  the  abdomen  is  incised  the  appearance  of  the  liver 
should  lead  the  surgeon  to  a  correct  interpretation  of  the  condi- 
tion. The  adhesions,  the  shrunken  lobulated  appearance,  some- 
times to  the  extent  of  almost  complete  severance  of  a  portion  of 
the  liver,  the  presence  of  the  most  marked  changes  near  the 
suspensory  ligament,  and,  as  sometimes  happens,  the  discovery  of 
associated,  usually  small  gummata  should  remove  all  doubts. 

Gummata  of  the  Liver. — Gumma  of  the  liver,  like  cirrhosis,  is  a 
late  manifestation.  The  gummata  usually  appear  on  the  surface 
of  the  liver,  although  they  may  sometimes  be  situated  deeply 
within  its  substance.  They  may  be  single  or  multiple,  and  are 
variable  in  size,  from  the  size  of  a  hazlenut  to  that  of  an  orange. 
They  are  sharply  delimited  from  the  liver  substance,  and  may 
be  situated  so  closly  together  that  their  shape  is  altered  by  pres- 
sure. They  usually  grow  in  a  more  or  less  spheric  shape,  except 
where  the  contour  is  altered  by  pressure.  They  are  firm  and 
somewhat  elastic.  Sometimes  these  gummata  are  surrounded 
by  a  dense  capsule.  Gummata  of  the  liver  are  found  most  fre- 
quently in  the  neighborhood  of  the  suspensory  ligament,  the 
portal  vein,  and  the  lower  margin.  Adhesions  may  form  over  the 
surface  of  superficial  gummata,  binding  them  to  adjacent  struc- 
tures. A  very  characteristic  feature  frequently  observed  is  the 
situation  of  the  gumma  in  the  bottom  of  a  pocket  produced  in  the 
liver  surface  by  cicatricial  contraction.  On  incision  into  the  light 
yellowish  gumma  the  central  portion  shows  caseated  material, 
and  surrounding  this  is  a  peripheral  zone  of  "grayish,  glassy  sub- 
stance"; on  the  contrary,  the  cut  surface  sometimes  presents  a 
homogeneous  appearance. 

Diagnosis. — Manifestly,  the  presence  of  gummata  in  the  liver 
may  cause  great  confusion  in  differentiation.  These  cases  are  often 
at  first  without  symptoms.  Later  inflammation  of  the  liver  or  of 
its  peritoneal  covering  and  amyloid  degeneration  may  occur  and 
produce  severe  symptoms,  causing  pain  in  the  region  of  the  liver. 
Digestive  disturbances  may  be  marked  and,  if  contraction  of  the 
liver  occurs,  hemorrhage  from  the  esophagus  or  stomach  may  ap- 
pear. The  patient  loses  weight  and  becomes  pale  and  cachectic. 
The  liver  is  usually  of  normal  size  and  is  nodulated.  The  spleen 
is  usually  enlarged.  Albuminuria  is  frequently  present. 

Gummatous  hepatitis  is  especially  likely  to  be  confused  with 
tumors  of  the  liver  and  with  distention  of  the  gall-bladder.  If  the 
gummata  are  so  situated  as  to  obstruct  the  bile-passages,  jaundice, 
intense  and  persistent,  will  occur,  and,  if  they  press  upon  the  por- 
tal vein,  ascites  and  other  evidences  of  portal  obstruction  will  be 
found.  Even  after  incision  into  the  abdominal  cavity  it  may  be 
impossible  to  differentiate  between  gummata  and  tumors,  espe- 


SYPHILIS  329 

oially  sarcomata,  and  resection  of  the  liver  has  been  performed  in 
such  cases.  Tuberculosis  of  the  liver  may  likewise  be  confused 
with  gummata.  The  yellowish  appearance,  the  hardness  asso- 
ciated with  elasticity,  and  the  "hard,  glassy  connective-tissue  cap- 
sule," as  well  as  the  sites  of  predilection,  are  the  chief  local  features 
characterizing  gummata  of  the  liver  and  distinguishing  them 
from  cancer,  sarcoma,  and  tuberculous  masses. 

Syphilis  of  the  Spleen. — During  the  secondary  stage  of  syphilis 
tin1  spleen  becomes  enlarged,  but  does  not  produce  symptoms. 
In  the  tertiary  stage  gummata  may  frequently  develop  in  it,  or 
inflammation  may  appear  producing  enlargement,  induration,  and 
slight  tenderness  of  the  organ.  Leukocytosis  may  be  present. 

In  congenital  syphilis  the  spleen  may  be  enlarged  to  four 
or  five,  exceptionally  even  to  ten,  times  its  normal  size.  It  may 
contain  gummata  or  an  excess  of  connective  tissue,  which  forms 
at  the  expense  of  spleen  parenchyma.  Early  enlargement  of  the 
liver  with  subsequent  reduction  hi  size,  associated  with  syn- 
chronous enlargement  of  the  spleen,  is  very  suggestive  of  syphilis. 
On  the  other  hand,  a  distinct  but  inconstant  hyperplasia  of  the 
organ  may  take  place  in  congenital  syphilis. 

Syphilis  of  Pancreas. — The  pancreas  is  seldom  affected  in 
syphilis,  and  when  affected  it  is  usually  hi  the  hereditary  cases. 
The  organ  is  enlarged  and  indurated  from  chronic  pancreatitis. 
( i  ultimata  are  rarely  seen,  and  the  condition  does  not  produce 
characteristic  symptoms,  being  overshadowed  by  more  serious 
involvement  of  other  structures.  In  acquired  syphilis  the  pan- 
creas may  be  inflamed  primarily  as  a  result  of  specific  infection; 
thi-  in  marked  contrast  to  the  usual  forms  of  pancreatitis,  which 
arc  secondary  to  diseases  of  the  gall-bladder  and  bile-ducts.  In 
syphilis  of  the  pancreas  the  secretory  tissue  may  be  partially  or 
almost  entirely  obliterated  by  new-formed  tissue,  but  the  islands 
of  Langerhans  remain  intact,  though  ensheathed  by  connective 
tissue. 

Syphilis  of  the  Testicles. — Two  forms  of  syphilis  of  the  tes- 
ticles are  seen — fibrous  orchitis  and  gummatous  orchitis. 

Fihrous  orchitis  appears  as  an  induration  of  the  body  of  the 
testicle  and  the  parenchyma  disappears.  The  gland  after  a  period 
of  enlargement  grows  smaller  as  a  rule;  may  become  very  small 
ami  hard.  The  epididymis  and  tin-  >crotum  an-  not,  as  a  rule, 
affected,  and  there  is  no  means  of  making  a  correct  diagnosis  except 
by  collateral  >ymptom<  and  signs. 

Gummatous  orchitis  affects  the  body  of  the  testicle,  very  rarely 
the  epididymis,  while  tuberculosis  begins  in  the  latter.  This  is 
one  of  the  most  common  sites  of  tertiary  involvement,  although 
the  te-ticle  may  be  affected  during  the  secondary  stage.  In  gum- 


330  PRINCIPLES   OF   SURGERY 

matous  orchitis  there  is  always  more  or  less  fibrosis  of  the  testicle 
associated  with  it.  The  condition  is  usually  painless,  frequently 
bilateral  and  chronic,  and  may  produce  great  damage  to  the 
structure  before  it  is  recognized.  The  gummata  may  be  very 
small  or  reach  the  size  of  a  bantam's  egg.  The  epididymis,  even 
when  the  testicle  is  much  enlarged,  can  usually  be  recognized  and 
is  rarely  invaded.  The  tunica  vaginaiiis  is  thickened  and  its 
cavity  obliterated  by  adhesions.  Gummatous  orchitis  is  less  likely 
to  be  followed  by  softening  than  tuberculous  nodules.  Sometimes 
softening  of  these  gummata  does  occur,  however,  followed  by 
rupture  and  discharge  on  the  scrotal  surface;  when  this  occurs, 
a  fungus  growth  of  granulation  tissue  may  appear  at  the  mouth 
of  the  sinus;  this  growth  is  gummatous  and  is  called  syphilitic 
fungus.  The  masses  may  disappear  by  resolution  or  become  partly 
calcified,  and  finally  fatty  degeneration  of  the  gummata  may  occur, 
and  they  be  replaced  by  cicatricial  masses.  One  cannot  hope  for 
resorption  of  old  gummata  which  are  surrounded  by  dense  con- 
nective tissue. 

It  is  extremely  difficult  to  differentiate  syphilitic  orchitis  from 
the  other  forms.  The  most  valuable  signs  are  the  chronic  course, 
the  absence  of  pain  and  usually  of  sensitiveness,  and  the  little 
tendency  to  break  down  into  suppurating  foci. 

Syphilis  of  the  Nervous  System. — From  a  surgical  standpoint 
the  chief  syphilitic  lesions  affect  the  central  nervous  system, 
and  are  due  to  the  formation  of  gummata  of  the  brain  or  men- 
inges;  they  usually  originate  in  the  latter  and  are  preceded  by 
syphilitic  meningitis,  which  has  a  predilection  for  the  base  of  the 
brain.  By  enlargement  the  nodules,  single  or  multiple,  extend 
into  the  brain  substance.  Slight  trauma  predisposes  the  injured 
tissue  to  gummatous  formation.  Gummata  of  the  brain,  as  well 
as  other  brain  lesions,  occur  usually  within  the  first  year,  and 
rarely  after  the  tenth  year,  of  infection.  The  symptoms  pro- 
duced are  identical  with  those  caused  by  tumors  similarly  located. 
If  a  basal  gummatous  meningitis  is  present,  certain  cranial  nerves 
may  be  impaired  in  function  by  the  formation  of  cicatricial  tissue. 
The  third  nerve  is  most  frequently  affected. 

Besides  gummata  of  the  brain  and  meninges,  syphilitic  nodules, 
protruding  from  the  inner  table  of  the  skull  and  from  the  bones 
of  the  base,  may  produce  pressure  symptoms.  Syphilis  of  the 
dura  and  of  the  bony  encasement  of  the  brain  is  much  more 
likely  to  invade  the  brain  than  tuberculosis  is. 

Syphilis  of  the  spinal  cord  is  rare;  it  appears  in  the  form  of 
gummata,  which  frequently  are  multiple  and  connected  with  some 
of  the  meningeal  coats.  The  local  symptoms  are  identical  with 
those  of  tumor. 


SYPHILIS  331 

Prognosis  of  Surgical  Syphilitic  Lesions. — When  one  considers 
that  the  lesions  of  syphilis  which  are  classed  as  surgical  conditions 
an-  cither  the  result  of  malignant  infection,  poor  resistance,  failure 
to  respond  to  treatment,  or  inadequate  and  neglected  treatment,  it 
is  manifest  that  the  prognosis  of  surgical  syphilis  is  necessarily 
Hindi  worse  than  that  of  ordinary  syphilis.  The  disease  .belongs 
to  medicine  rather  than  to  surgery,  and  it  is  only  hi  rare  cases  of 
extraordinary'  manifestations  that  it  is  to  be  considered  surgical. 
Thru  even  only  certain  localized  lesions  are  amenable  to  surgery; 
the  general  conditions  out  of  which  these  have  arisen  have  noth- 
ing to  do  with  surgery.  The  nature,  location,  and  extent  of  the 
lesion  likewise  has  much  to  do  with  the  prognosis.  Many  of  the 
surgical  syphilitic  lesions  refuse  to  respond  to  antisyphilitic 
thrrapy,  and  others  create  such  emergency  that  there  is  no  time 
for  delay.  The  therapeutic  test  is  thus  shown  not  to  be  always 
diagnostic.  If  the  diseased  condition  can  be  removed  with  safety, 
ami  if  the  administration  of  treatment  be  followed  up  afterward, 
the  prognosis,  while  not  of  the  best,  is  very  good,  provided  that 
hopeless  damage  has  not  been  done  hi  other  organs. 

Treatment  of  Syphilis. — The  treatment  of  the  surgical  mani- 
festations of  syphilis  depends  on  the  nature  of  the  lesion  and  the 
int  ( -rference  it  produces  with  function,  and  on  the  liability  of  spread 
or  of  continued  damage  to  the  structure  in  which  it  appears.  If 
the  lesion  is  causing  no  immediate  danger,  antisyphilitic  remedies 
may  be  administered.  If  failure  follows  this,  and  no  future  harm 
is  likely  to  come  of  it,  the  lesion  may  be  left  intact.  When  de- 
structive processes  begin,  or  when  serious  interference  with  func- 
tion has  occurred,  and  no  response  can  be  had  from  heroic  treat- 
ment, when  the  emergency  is  such  that  no  time  can  be  spared, 
and.  lastly,  when  hopeless  permanent  sequela  follow,  as  hi  cases 
of  stricture  of  the  alimentary  tract,  then  surgery  must  be  done, 
and.  other  things  being  equal,  the  sooner  it  can  be  done  the  better 
the  chance  of  recovery,  for  in  such  cases,  after  removal  of  the 
particular  intractable  lesion,  the  remaining  manifestations  respond 
to  the  usual  plan  of  treatment.  The  plan  of  surgical  treatment  of 
syphilitic  It-inn-  i<  iu  no  way  different  from  that  of  similar  condi- 
tion- arising  from  other  causes.  For  example,  necrosis  of  bone  is 
treated  by  thorough  removal,  gummata  are  treated  as  benign 
tumors  -iiuilarly  located  would  be,  and  stricture  by  the  usual 
plans  of  division,  incision,  or  resection. 

At  the  >ame  time  that  surgical  treatment  is  done  the  most 
a— idnou-  attention  mu-t  l>e  directed  toward  general  treatment. 
The  removal  of  the  particular  surgical  condition  is  not  a  treatment 
for  -Yphilis,  but  for  an  unfortunate  con>e<|uence  of  it-  presence, 
and  unle«  the  surgeon's  attention  !>»•  directed  toward  the  cause 


332  PRINCIPLES   OF   SURGERY 

of  the  trouble,  not  only  may  he  fail  to  get  a  satisfactory  local  result, 
but  he  may  be  confronted  by  more  serious  and  hopeless  manifesta- 
tions. 

The  accepted  treatment  for  syphilis  is  the  administration  of 
mercury.  This  is  the  treatment  to  be  relied  on  as  a  cure  in  all 
stages.  If  the  case  has  tertiary  lesions,  or  even  severe  (malignant) 
secondary  lesions,  iodin  should  be  administered  in  some  form, 
usually  as  potassium  iodid;  its  action  as  a  resolvent  reduces  the 
danger  from  gummatous  and  inflammatory  processes.  It  may  be 
accepted,  then,  that  both  these  drugs  are  indicated  in  any  form 
of  surgical  syphilis.  In  all  cases  potassium  iodid  is  administered 
per  orem,  but  mercury  may  be  administered  by  various  methods 
and  in  various  forms. 

The  oldest  method  of  giving  mercury  for  syphilis  is  by  mouth. 
Protoiodid,  bichlorid,  and  gray  powder  are  the  favorites  in  the 
order  named.  The  dose  should  be  administered  three  or  four 
times  daily,  and  should  be  small  at  the  beginning,  and  increased 
to  a  point  just  short  of  tolerance,  which  is  indicated  by  griping, 
purging,  or  blueness  of  the  gums.  Especial  attention  should  be 
paid  to  general  hygiene,  particularly  that  of  the  mouth;  the  teeth 
must  be  kept  clean.  The  patient's  habits  should  be  moderate  and 
exemplary,  and  tobacco,  alcohol,  rich  food,  and  condiments  must 
be  used  in  stoical  moderation  or  preferably  not  at  all.  Abundant 
water  should  be  taken,  preferably  alkaline  waters,  and  the  general 
health  conserved  hi  every  possible  way.  All  excesses  must  be 
avoided,  and  the  treatment  should  be  kept  up  continuously  or, 
if  deemed  best,  with  occasional  short  intermissions. 

The  second  method  of  administering  mercury  is  by  inunction — 
a  very  safe,  effective,  and  rapid  method.  It  is  objectionable  on 
account  of  the  unpleasantness  of  administration  and  the  time 
consumed  at  each  treatment,  as  well  as  the  unpleasant  irritation 
of  the  skin  which  sometimes  occurs.  Unguentum  hydrargyri  is 
the  form  used,  and  it  is  rubbed  into  the  skin  of  the  abdomen,  back, 
and  inner  surfaces  of  the  thighs  in  daily  doses  of  2  or  3  drams. 
The  inunctions  should  be  made  on  different  surfaces  at  successive 
treatments  if  the  skin  shows  signs  of  irritation. 

Of  recent  years  the  hypodermic  and  intramuscular  methods  of 
administering  mercury  have  largely  displaced  the  preceding  two. 
It  is  more  effective,  quicker  in  action,  more  definite  in  dosage, 
and  keeps  the  patient  constantly  under  his  physician's  care. 
It  is  the  ideal  method  for  administering  mercury  to  syphilitics, 
and  is  objectionable  only  in  the  slight  pain  at  the  time  of  injec- 
tion, and  the  aching  of  the  thigh  and  leg  consequent  upon  the  first 
few  doses,  or  upon  depositing  the  dose  too  close  to  a  nerve  or  sub- 
cutaneously. 


SYPHILIS  333 

The  preparations  used  for  this  method  are  numerous,  the 
nil  i>t  i>opular  being  calomel  and  mercuric  chlorid  for  rapid  mercurial- 
i/at  i«m;  and  gray  oil,  salicylate  of  mercury,  and  the  iodid  of  mer- 
cury for  the  ordinary  cases.  The  soluble  salts  may  be  adminis- 
tered hypodermically;  the  insoluble,  by  intramuscular  injection. 
Tin-  injection  of  the  insoluble  preparations  and  all  oily  solutions 
should  be  guarded  by  the  following  precaution,  to  avoid  delivery 
of  t  he  medicament  into  a  vein  and  the  resultant  dangers  of  embo- 
lism:  The  needle  should  be  filled  with  the  mixture  and  inserted 
to  the  proper  depth;  the  syringe  is  then  disconnected  from  the 
needle,  and  observation  made  for  a  few  seconds  to  determine  if 
blood  escapes  through  the  needle  or  if  the  mixture  runs  out.  In 
either  instance  the  point  of  the  needle  must  be  shifted  to  another 
point  and  the  same  procedure  repeated.  It  is  unnecessary  to 
withdraw  the  needle  completely  to  accomplish  this.  Now  the 
medicament  is  injected  and  a  bit  of  adhesive  plaster  is  stuck  over 
the  opening  if  bleeding  or  leakage  occurs.  In  the  ordinary  course 
of  treatment  once  a  week  is  often  enough  to  make  injections  with 
the  insoluble  salts;  the  soluble  salts  must  be  injected  more  fre- 
quently and  in  proportionately  smaller  doses.  However,  the  dose 
anil  the  frequency  of  administration  depends  very  much  on  the 
individual  case.  In  an  emergency  the  administration  should  be 
determined  by  the  limit  of  tolerance. 

Salvarsan  and  neosalvarsan  have  recently  been  added  to  the 
list  of  useful  antisyphilitic  remedies.  They  are  not  to  be  regarded 
as  cures,  as  it  was  first  hoped,  but  as  very  useful  drugs,  especially 
in  those  cases  that  fail  to  respond  to  mercury,  in  malignant  cases, 
in  emergencies,  and  in  those  cases  where  serious  late  manifestations 
have  arisen.  Their  use  does  not  avoid  the  necessity  of  mercury 
and  ioclin,  although  it  seems  from  our  present  knowledge  that  they 
materially  shorten  the  time  of  treatment.  The  dose  of  salvarsan 
usually  given  is  0.6  gram,  and  it  can  be  given  either  by  the  intra- 
muscular or  the  intravenous  method.  In  the  latter  instance  it 
nm-t  be  much  more  diluted  and  accurately  brought  to  a  slightly 
alkaline  reaction.  Salvarsan  cannot  be  accepted  as  a  harmless 
remedy,  and  is  contra-indicated  in  all  cases  of  arterial,  cardiac,  and 
renal  lesions  not  of  syphilitic  origin. 

lodin  is  almost  universally  administered  as  potassium  iodid. 
The  initial  doses  are  small,  5  to  10  gr.  in  solution  three  times 
a  day,  and  >nli-equent  doses  arc  gradually  increased  till  a  daily 
dose  of  100  to  200  gr.  is  readied.  It  is  especially  useful  in  late 
secondary  and  tertiary  lesions. 


CHAPTER   XVIII 
BLASTOMYCOSIS 

Definition. — Blastomycosis  embraces  the  group  of  lesions 
produced  by  blastomyces,  one  of  the  budding  fungi.  It  may  be 
simply  a  cutaneous  disease  (blastomycotic  dermatitis),  or  nodes, 
abscesses,  ulcers,  or  sinuses  may  appear  beneath  the  skin  and  be 
followed  by  extensive  cicatrization.  The  mucous  and  serous 
membranes,  the  osseous  system,  the  lymphatics,  and  practically 
all  the  viscera  may  be  involved  hi  the  generalized  cases. 

Etiology. — The  fungus  belongs  to  the  yeast-forming  group, 
and  has  been  known  to  cause  the  disease  over  a  very  wide  geo- 
graphic area.  It  is  found  hi  North  and  South  America,  most  of  the 
European,  and  some  of  the  Asiatic  countries.  The  fungus  as  ob- 
served in  the  tissues  is  of  a  roundish  shape,  encapsulated,  and  has 
a  clear  zone  lying  immediately  within  the  capsule.  The  contents 
of  the  cell  are  granules,  which  are  not  of  uniform  size  and  are  of 
irregular  shape.  Occasionally  a  vacuole  is  found.  The  fungus 
multiplies  by  budding  (granulation)  and  possibly  by  spore  forma- 
tion. It  is  easily  cultivated  artificially. 

Pathology. — The  pathologic  changes  are  those  of  an  inflamma- 
tory process,  and  in  many  ways  resemble  the  lesions  of  tubercu- 
losis, with  the  exception  that  blastomycosis  is  prone  to  produce 
suppuration,  either  hi  the  form  of  miliary  abscesses,  so  common 
in  the  cutaneous  form,  or  large  abscesses,  such  as  appear  in  the 
viscera,  subcutaneous  tissue,  lymph-nodes,  and  bones.  Giant 
cells  are  present  in  all  the  lesions,  and  masses  resembling  tubercles 
are  frequently  found.  The  infected  tissues  present  the  ordinary 
findings  of  pus,  with  blastomycetes  distributed  through  them  as 
well  as  hi  the  pus.  There  is  scarcely  an  important  organ  within 
the  body  that  has  not  been  found  affected,  though  the  number  of 
cases  thoroughly  studied  has  been  comparatively  small. 

Cutaneous  Blastomycosis. — This  is  the  type  most  frequently 
seen,  although  it  may  be  associated  with  general  blastomycosis. 
There  is  a  marked  resemblance  between  cutaneous  blastomycosis 
and  lupus.  It  may  involve  only  small  areas  of  the  integument,  or 
they  may  be  large,  numerous,  and  widely  distributed  over  the 
body.  The  face  is  most  frequently  affected.  The  lesion  is  ele- 
vated above  the  surrounding  skin  and  has  a  flattened  surface 
which  has  the  appearance  of  verruca,  and  is  ulcerated  or  covered 

334 


BLA8TOMTCOSI8  335 

with  a  scab.  If  it  is  ulcerated  there  is  a  purulent  discharge. 
By  pressure  pus  may  be  forced  from  those  lesions  already  dis- 
ci i: irking.  Surrounding  this  elevated  surface  is  a  sloping  border, 
\  <  m.  in  width,  which  is  of  a  reddish,  cyanotic  hue  and  shows 
large  numbers  of  miliary  abscesses,  which  contain  a  tenacious 
mucopus,  which,  on  microscopic  examination  or  culture,  reveals 
blastomycetes.  Cutaneous  blastomycosis  runs  a  chronic  and  un- 
even course,  exacerbations  alternating  with  quiescence.  Heal- 
ing occurs  completely  in  some  of  the  lesions;  in  others  it  is  all 
In  it  complete,  with  only  a  few  minute  abscesses;  hi  still  others  all 
stages  of  the  lesion  are  present,  from  the  advancing  zone  bounded 
l>y  the  bluish-red  border  to  complete  cicatrization. 

Systemic  Blastomycosis. — The  constitutional  symptoms  of  gen- 
eral blastomycosis  are  less  marked  than  the  gravity  of  the  condi- 
tion would  indicate.  The  disease  is  almost  invariably  fatal,  yet 
the  course  of  it  is  rather  mild  so  far  as  the  general  reaction  is 
concerned.  The  patients  have  anorexia,  are  weak,  and  become 
progressively  weaker,  until  they  may  be  prostrated.  There  is 
progressive  loss  of  weight  and  increase  of  anemia.  The  tem- 
perature is  inconstant,  varying  from  an  occasionally  persistent 
subnormal  registration  to  a  maximum  of  103°  F.  A  moderate 
fever  is  the  rule.  The  pulse  varies  with  the  temperature,  as  does 
the  respiration,  which  is  apparently  not  much  disturbed  by  severe 
and  extensive  pulmonary  involvement.  The  cases  so  far  observed 
have  been  largely  free  from  pain  and  from  involvement  of  the 
lymphatics.  Special  symptoms  arise  from  affection  of  the  various 
organs;  diarrhea  may  follow  an  invasion  of  the  intestine,  and  the 
bones  and  joints  may  show  evidence  of  an  osteomyelitis  or  arthri- 
tis. Very  characteristic  are  the  subcutaneous  nodules,  which  break 
down  and  suppurate,  forming  abscesses  of  various  sizes,  which 
rupture,  discharging  their  contents  on  to  the  surface,  and  result 
in  chronic  sinuses  or  ulcers,  which  occasionally  are  very  large, 
often  undermined,  and  disposed  to  spread.  The  presence  of  a 
cough  and  expectoration  of  bloody  sputum  has  frequently  led  to 
a  mi-taken  antrmortem  diagnosis  of  tuberculosis,  and  occasionally 
to  a  similar  postmortem  error.  Such  a  diagnosis  is,  furthermore, 
encouraged  by  the  physical  signs  elicited  by  examination  of  the 
chest. 

Diagnosis. — Blastomycosis  of  the  skin  may  be  confused  with 
verrucous  tuberculosis,  with  epithelioma,  and  with  tertiary  syph- 
ilis. 

( ieneral  blastomycosis  is  confused  with  general  tuberculosis. 
In  either  form  of  the  disease  microscopic  or  cultural  measures  will 
l>e  necessary  to  determine  the  cause. 

Prognosis. — Cutaneous  blastomycosis  usually  recovers,  but  re- 


336  PRINCIPLES   OF   SURGERY 

currence  is  frequent.  The  prognosis  in  general  blastomycosis  is 
extremely  grave,  and  the  mortality  is  more  than  75  per  cent. 

Treatment. — The  only  therapy  proving  beneficial  so  far  is 
potassium  iodid,  recommended  by  Bevan.  The  drug  must  be 
administered  in  large  doses,  reaching  sometimes  as  high  as  600 
gr.  a  day,  administered  with  large  quantities  of  fluid.  It  is 
unwise  to  begin  on  such  large  doses,  but  they  must  be  reached 
by  gradual  increase  in  the  daily  dose. 

Excision  is  of  value  only  in  cutaneous  cases  where  the  lesion 
is  so  situated  that  it  can  be  completely  removed.  Dr.  Bevan  rec- 
ommends sulphate  of  copper,  gr.  |  t.  i.  d.,  internally,  and  a 
dressing  wet  in  a  1  per  cent,  solution  of  the  same  drug.  X-rays 
may  hasten  the  healing  of  skin  lesions.  Abscesses,  ulcers,  fistulae, 
and  necrosed  bone  may  be  treated  according  to  the  rules  for 
similar  lesions  produced  by  other  causes,  but  with  much  less  hope 
for  success. 


CHAPTER   XIX 
SPOROTRICHOSIS 

SPOROTRICHOSIS  is  an  inflammatory  process  caused  by  the 
fungus  Sporotrichum  Schenckii  (Beurmanni),  and  characterized 
by  the  formation  of  gumma-like  nodules,  which  soften,  rupture, 
and  form  ulcers  and  sinuses  which  run  a  very  chronic  course. 

Etiology. — The  fungus  Sporotrichum  Schenckii  (Beurmanni) 
is  a  widely  distributed  organism,  and,  since  its  description  in  1898 
by  Schenk  and  Hektoen  as  a  disease  producer,  has  been  recog- 
ni/ed  in  a  constantly  increasing  number  of  cases  over  widely 
separated  sections.  The  fungus  is  found  on  grain,  trees,  grass, 
and  such  like.  In  the  United  States  the  greater  number  of  cases 
have  been  found  in  the  Middle  West.  It  has  also  been  studied 
in  France  and  Switzerland.  The  organism  gains  entrance  into 
the  tissues  through  an  abrasion  or  wound,  and  is  probably  fre- 
quently contracted  by  man  from  the  horse,  which  is  also  quite 
frequently  affected. 

Pathology. — The  lesion,  as  it  appears  at  first,  is  a  slowly  growing 
nodule  in  the  form  of  a  sphere,  unless  influenced  by  surrounding 
structures,  as  happens  when  it  lies  over  a  superficial  bone,  as  the 
tibial  crest.  It  is  solid  at  first,  and  resembles  a  gumma  or  a  sar- 
coma. As  the  disease  progresses  the  central  portion  breaks  down 
into  a  fluid  resembling  pus,  less  yellow  than  "good  laudable  pus," 
and  of  a  waxy  appearance.  The  pus  is  viscid,  a  very  important 
differential  point  in  distinguishing  it  from  ordinary  pus  produced 
by  pyogenic  bacteria.  It  is  frequently  brownish  or  reddish  brown, 
owing  to  the  admixture  of  blood.  The  nodules,  as  a  rule,  vary  in 
si/e  from  that  of  a  hazelnut  to  that  of  a  walnut.  Occasionally  an 
al»n»  i<  seen  of  10  to  15  cm.  in  diameter. 

As  the  destruction  of  tissue  approaches  the  surface  the  skin 
breaks  down  and  rupture  occurs,  leaving  a  round  ulcer  with 
Undermined  edges  and  surrounded  by  a  red  zone  ^  to  1  cm. 
in  width.  This  border  may  become  a  purplish  red  or  later  dis- 
tinctly brown.  Instead  of  an  ulcer  a  sinus  may  form.  In  either 
instance  there  is  a  continual  discharge  of  pus  from  the  lesion. 
The  aliscosses  are  lined  with  a  thin  fibrous  layer  and  with  necrotic 
ti»ue.  If  there  are  several  nodes  in  the  same  region  they  seem 
to  communicate  with  each  other  by  narrow  tracts,  through  which 
a  probe  may  be  passed,  indicating  that  the  nodules  form  by  the 
extrusion  of  the  fungi  through  the  tissues. 

22  337 


338  PRINCIPLES   OF   SURGERY 

The  pus  may  contain  small  elongated  bodies  which  resemble 
atypically  the  lumps  found  in  actinomycotic  pus. 

The  lymphatic  vessels  and  nodes  have  not  been  invaded  in  any 
of  the  cases  reported. 

Symptoms. — The  period  of  incubation  was  ten  and  thirteen 
days  respectively  in  two  cases  unintentionally  inoculated  by 
Dind  in  an  attempt  to  produce  a  cutaneous  reaction  with  fluids 
which  had  accidentally  escaped  sterilization. 

Sporotrichosis  is  eminently  a  symptomless  disease.  There 
are  no  constitutional  symptoms.  The  blood  remains  normal,  the 
temperature  and  general  well  being  are  undisturbed.  The  local 
symptoms  are  almost  as  emphatically  negative.  There  is  ex- 
ceedingly little  or  no  pain  or  tenderness.  The  diagnosis  must, 
therefore,  be  made  by  the  appearance  of  a  painless  nodule,  fol- 
lowed by  more  or  less  numerous  others  scattered  over  the  body, 
and  situated  either  subcutaneously  or  in  the  muscles.  The  nodules 
are  usually  movable,  but  may  occasionally  be  more  or  less  attached 
to  surrounding  structures.  The  redness  appears  only  as  the 
lesion  approaches  the  surface,  but  it  remains  (red  or  brown)  so 
long  as  the  sinuses  and  ulcers  persist.  When  suppuration  ceases 
a  scab  forms  over  the  ulcer  and  healing  occurs,  leaving  usually  a 
fine  thin  cicatrix  which  gradually  becomes  pale;  occasionally 
the  cicatrix  resembles  a  keloid. 

Diagnosis. — Sporotrichosis  must  be  distinguished  especially 
from  tertiary  syphilis,  actinomycosis  and  tuberculosis  of  the  skin, 
and  sarcoma. 

The  discovery  of  the  causative  micro-organism  is  the  only 
positive  means  of  diagnosis.  Sporotrichum  can  sometimes  be 
discovered  in  the  pus  from  the  nodules.  Dind  gives  the  following 
method  of  Lumiere  and  Becue,  as  modified  by  Galli-Valerio,  for 
staining:  "The  pus  is  smeared  in  a  thin  layer  on  the  slide  or 
cover-glass  and  gently  dried  over  a  flame.  A  drop  of  ether  is  al- 
lowed to  fall  upon  the  specimen  and  remain  for  some  seconds; 
then  a  few  drops  of  a  10  to  20  per  cent.  KOH  solution  (fresh)  is 
used;  then  wash  in  water  and  immerse  in  a  5  per  cent,  aqueous 
solution  of  eosin  for  ten  to  fifteen  minutes;  after  which  wash  with 
a  concentrated  solution  of  sodium  acetate  until  the  specimen  be- 
comes a  light  rose-red  color.  Wash  with  water,  dry  by  the  flame, 
mount  hi  Canada  balsam"  (Deutsche  Zeitschrift  fur  Chirurgie, 
116  B). 

A  cutaneous  reaction  may  be  obtained  after  the  disease  has 
endured  six  weeks  or  more.  The  culture  is  made  in  fluid  media  and 
filtered.  Trituration  with  sterile  sand  or  infusorial  earth  prior  to 
filtration  gives  a  more  marked  reaction.  The  reaction  appears  in 
seventeen  or  eighteen  hours  and  lasts  two  or  three  days.  It  is 


SPOROTRICHOSIS  339 

more  accurate  when  administered  endermically  than  by  scarifica- 
tion. 

When  the  fungus  cannot  be  found  in  the  pus  resort  must  be 
had  to  cultures. 

Prognosis. — It  appears  that  the  outlook  for  life  is  good,  but 
the  possibility  of  the  physician  producing  a  definite  cure  is  prob- 
lematic, as  the  lesions  may  continue  to  form  under  the  most 
assiduous  treatment. 

Treatment. — The  treatment  chiefly  relied  upon  is  iodin, 
usually  in  the  form  of  KI,  administered  internally,  and  hi  doses 
gradually  increased  to  200  to  300  gr.  daily.  It  is  significant 
that  the  cases  inoculated  by  Dind  were  at  the  time  receiving 
enormous  doses  of  potassium  iodid.  R.  L.  Sutton  recommends 
the  additional  employment  of  daily  local  applications  of  1  per 
cent,  cresol  solution  after  the  abscesses  rupture  or  are  opened. 


CHAPTER    XX 
HEMORRHAGE 

THE  escape  of  blood  resultant  upon  injury  to  the  parts  may 
be  upon  a  mucous  or  cutaneous  surface,  into  one  of  the  closed 
serous  cavities  of  the  body,  or  into  the  tissues  where,  by  separation 
of  the  structures  from  one  another,  large  quantities  may  accu- 
mulate. In  all  these  cases  the  effect  produced  upon  the  patient 
is  the  same,  namely,  a  very  definite  group  of  symptoms  arising 
as  the  result  of  withdrawal  of  a  certain  amount  of  blood  from  the 
vessels  and  the  heart.  If  the  hemorrhage  escapes  directly  from 
the  wound  to  a  cutaneous  surface  or  an  accessible  mucous  surface 
it  is  a  visible  hemorrhage;  if  it  escapes,  however,  into  a  hollow 
viscus,  anatomic  space,  or  one  of  the  serous  cavities  it  is  a  con- 
cealed hemorrhage. 

The  extent  of  hemorrhage  depends  upon  the  various  factors, 
such  as  the  size  of  the  bleeding  vessel,  the  blood-pressure  in  that 
vessel,  the  ease  of  the  escape  of  the  blood  after  passing  from  the 
lumen  of  the  vessel,  the  condition  of  the  vessel,  the  nature  of  the 
wound  in  the  vessel  wall,  and  the  coagulability  of  the  blood. 
In  the  first  place,  the  freedom  of  hemorrhage  from  heart,  artery, 
vein,  or  capillaries  occurs  hi  the  order  named.  An  individual  may 
bleed  to  death  in  a  few  seconds  from  an  injury  to  a  large  artery 
or  the  heart,  and  almost  as  suddenly  from  a  large  vein,  but  the 
smaller  arteries  bleed  much  more  rapidly  than  veins  of  similar 
size.  Severance  of  the  vena  cava  or  of  the  aorta,  as  well  as  the 
heart,  produces  instant  death,  as  the  whole  volume  of  circulating 
blood  is  stopped  when  such  an  injury  is  produced.  Hemorrhage 
from  an  artery  is  characterized  by  its  ejection  in  spurts  and  its 
red  color;  that  from  veins,  by  its  steady  flow,  easily  prevented  by 
slight  tension  or  pressure,  and  the  dark  color.  Capillary  hemor- 
rhage comes  as  a  slow,  steady  issue  from  a  wounded  surface,  may 
be  red  or  dark,  and  appears  to  well  up  from  the  tissues  and  not 
definitely  from  one  or  more  points,  as  in  arterial  or  venous  hemor- 
rhage. 

Arterial  hemorrhage  is  influenced  very  materially  by  the 
blood-pressure;  hence,  wounds  of  large  arteries  and  of  small  arte- 
ries close  to  their  origin  from  large  arteries  bleed  more  vigorously 
than  those  whose  blood-pressure  is  lower.  On  the  other  hand, 
blood-pressure  influences  capillary  hemorrhage  but  slightly,  and 
venous  hemorrhage  perhaps  not  at  all. 

340 


HEMORRHAGE  341 

Hemorrhage  from  a  deeply  situated  vessel  of  moderate  size  is 
more  likely  to  stop  short  of  exsanguination  than  one  more  super- 
ficially placed,  owing  to  the  tendency  of  the  blood  to  clot  as  it  ap- 
proaches a  surface  and  comes  in  contact  with  the  tissues;  likewise, 
hemorrhage  from  a  wound  made  on  a  surface  densely  covered  with 
hair  is  less  dangerous  than  one  of  a  smooth  or  shaven  surface. 
If  the  bleeding  vessel  is  possessed  of  a  normal  structure,  the 
normal  contraction  of  its  muscular  coats  tends  to  reduce  the 
rate  of  bleeding,  but  if  the  vessel  has  undergone  degenerative 
changes  the  size  of  the  lumen  cannot  be  altered  by  such  a  process. 
Those  wounds  in  which  the  blood-vessels  are  simply  severed,  as  by 
iii( 'i-ion,  bleed  more  freely  than  those  where  the  vessel  is  crushed, 
torn,  or  twisted  in  two.  The  condition  of  the  blood  affects  its 
coagulability,  and  when,  by  the  presence  of  disease  or  by  idio- 
syncrasy, as  in  hemophilia,  this  essential  function  of  the  blood 
is  reduced  or  destroyed,  hemorrhage,  even  from  the  few  capil- 
laries injured  in  so  minute  a  wound  as  a  pin-stick,  may  prove 
uncontrollable. 

Symptoms  of  Hemorrhage. — A  relatively  large  quantity  of 
blood  may  escape  the  vessels  of  a  healthy  individual  without  pro- 
ducing perceptible  symptoms.  But  a  point  is  reached  beyond 
which  continued  hemorrhage  produces  marked  and  even  violent 
symptoms.  The  effect  of  hemorrhage,  in  other  words,  is  not  in 
proportion  to  the  quantity  of  blood  lost;  for  if  the  bleeding  is  con- 
trolled after  a  considerable  hemorrhage  the  patient  may  quickly 
react,  and  after  a  few  hours  show  no  signs  of  his  recent  loss  of 
blood;  but  a  very  moderate  additional  loss  may  suddenly  produce 
an  alarming  state  which  will  require  weeks  to  correct,  if,  indeed,  it 
bo  not  hopeless.  This  item  is  of  especial  importance  in  cases 
of  direct  transfusion  in  the  second  sitting  of  two-stage  operations, 
aii'l.  indeed,  in  all  operative  procedures  undertaken  subsequent 
to  a  recent  hemorrhage. 

The  symptoms  of  hemorrhage  are  pallor,  showing  best  in  the 
nail-  and  the  vermilion  border  of  the  lips  and  the"  mucous  mem- 
branes, thirst,  air-hunger  with  rapid,  sighing  respiration,  yawning, 
re-tic— nt— .  and  anxiety.  The  pulse  is  rapid  and  weak  and 
gradually  becomes  more  rapid,  then  uncountable,  and  constantly 
weaker.  The  blood-pressure  gradually  decreases,  the  tempera- 
ture become-  subnormal,  the  skin  is  pale,  clammy,  covered  with 
per-piration  and  cold,  and  the  patient  becomes  restless  and  anxious, 
and.  although  he  is  perfectly  conscious,  no  assurance  from  the  at- 
1endant<  will  abate  the  re-tie— lie— .  The  pupils  are  dilated  and 
the  vi-ion  is  impaired.  Tinnitus  may  be  present.  The  patient 
becomes  extremely  weak  and  the  voice  feeble.  In  chronic  cases 
of  bleeding,  where  there  is  a  continuous  loss  of  small  quantities 


342  PRINCIPLES   OF   SURGERY 

of  blood,  or  where  repeated  slight  hemorrhages  occur,  the  above 
symptoms  do  not  appear,  and  the  patient's  appearance  is  that  of 
anemia. 

Control  of  Hemorrhage. — The  control  of  hemorrhage  may  be 
done  prior  to  wounding  the  blood-vessels  or  subsequently;  it  may 
be  temporary  or  permanent.  Hemorrhage  from  capillaries,  veins, 
except  the  large  ones,  and  very  small  arteries  usually  stanches 
through  the  natural  processes  of  coagulation  and  contraction  and 
retraction  of  the  injured  vessel,  but  any  failure  of  this  occur- 
rence after  a  time  creates  a  demand  for  the  employment  of  arti- 
ficial hemostasis.  If  there  is  any  doubt  as  to  the  permanence 
of  natural  control  of  hemorrhage,  the  doubt  should  be  removed 
by  the  use  of  positive  methods,  for  often  the  terminal  thrombi 
which  occlude  the  open  vessel  mouths  are  dislodged  by  some 
accident  or  effort  and  dangerous  bleeding  takes  place.  In  opera- 
tive work,  as  has  been  shown  already,  there  are  other  cogent 
reasons  for  preventing  the  escape  of  blood  into  a  wound  or  a 
normal  cavity. 

Previous  to  an  operation,  in  many  regions  of  the  body,  it  is 
convenient  to  render  the  field  bloodless  on  account  of  thereby 
increasing  the  facility  to  work,  while  in  other  regions  such  a 
course  is  imperative  to  prevent  exsanguination  and  the  great 
delay  imposed  by  the  necessity  of  catching  and  ligating  bleeding 
vessels.  This  is  done  hi  the  extremities  by  the  application  of  a 
tourniquet,  preferably  above  the  elbow  or  the  knee,  for  it  is  easier 
to  control  hemorrhage  hi  those  parts  containing  one  bone  than  two. 
In  the  lower  extremity  the  tourniquet  is  applied  preferably  in  the 
middle  third  of  the  femur,  and  hi  the  upper  extremity  in  either 
the  upper  or  lower  third  of  the  humerus,  to  avoid  paralysis  of  the 
great  sciatic  and  the  musculospiral  nerve  respectively  by  making 
pressure  on  them  where  they  lie  close  to  the  bone.  Previous  to 
applying  the  tourniquet  to  an  extremity  the  part  may  be  rendered 
bloodless  by  elevating  the  limb  or  by  the  application  of  an  Es- 
march's  elastic  bandage,  beginning  at  the  digits.  This  plan  of 
conserving  the  blood  contained  in  the  part  is  an  excellent  one,  but 
cannot  be  safely  practised  hi  cases  of  gangrene,  infection,  or 
malignant  tumors.  A  similar  plan  has  been  devised  by  Momberg 
for  control  of  hemorrhage  in  vessels  below  the  navel  by  apply- 
ing a  rubber  tourniquet  around  the  abdomen.  Again,  prophy- 
lactic control  of  hemorrhage  may  be  practised  not  only  in  the 
extremities,  but  elsewhere,  if  the  trunk  arteries  are  easily  ac- 
cessible, by  the  application  of  temporary  ligatures  or  clamps 
(Crile)  immediately  before  the  operation;  the  coats  of  the  vessel 
should  not  be  injured  in  these  instances  by  too  forcible  compres- 
sion, and  the  ligature  or  clamp  should  be  loosened  as  soon  after 


HEMORRHAGE  343 

flushing  as  possible.  In  those  cases  where  the  surgeon  knows  he 
will  sever  the  artery  and  its  branches  during  his  operation  it  is 
often  feasible  to  avoid  the  necessity  of  ligating  many  bleeding 
vessels  by  tying  the  main  vessel  permanently  at  the  beginning. 

The  tune  limit  for  obstruction  of  a  vessel  depends  on  the  col- 
lateral  circulation.  In  all  cases  where  it  is  necessary  to  apply  a 
tourniquet  it  should  be  released  or  substituted  by  other  less  dan- 
gerous plans  as  soon  as  possible. 

Where  hemorrhage  is  expected  during  an  operation,  or  where 
there  are  bleeding  points  that  cannot  at  the  moment  be  attended 
to,  the  rate  of  hemorrhage  may  be  reduced  or  it  may,  indeed,  be 
controlled  by  placing  a  tourniquet  around  the  proximal  end  of 
one  or  more  extremities  sufficiently  tight  to  obstruct  the  veins 
without  collapsing  the  arteries,  "bleeding  the  patient  into  his  own 
Is."  This  has  the  advantage  of  adding  a  considerable  reduc- 
tion in  blood-pressure  to  other  applicable  measures,  and,  further, 
of  reserving  a  considerable  supply  of  blood  to  be  turned  loose 
upon  release  of  the  tourniquet. 

Control  of  Active  Bleeding. — The  temporary  means  for  control 
of  hemorrhage  are  those  mentioned  in  the  preceding  paragraphs, 
together  with  other  means  of  compression  of  the  bleeding  surface 
or  of  the  vessel  on  the  side  of  the  wound  from  which  the  hemor- 
rhage comes,  proximal  in  arterial,  distal  hi  venous,  hemorrhage. 
The  fact  must  not  be  lost  sight  of  that  certain  arteries,  like  the 
facial,  bleed  in  both  directions.  This  compression  may  be  made 
by  the  fingers  on  the  vessels  concerned,  or  by  pressure  on  the  open 
surface  with  gauze  or  cotton  swabs.  Necessarily  this  is  only  a 
temporary  control  if  the  vessels  are  large  or  if  they  bleed  actively, 
but  it  may  stanch  the  bleeding  completely  and  permanently  if 
from  capillaries  or  small  veins.  A  needle  may  be  passed  beneath 
the  bleeding  vessel,  if  superficial,  and  compression  be  produced 
by  \vrapping  a  thread  alternately  around  the  ends  of  the  needle 
and  across  the  vessel,  acupressure.  If  a  large  vessel  is  wounded 
at  a  point  for  the  moment  inaccessible,  a  finger  may  be  pushed 
1  irmly  into  its  lumen  until  it  can  be  reached  for  more  efficient 
henuxtaais. 

Am >t her  plan,  sometimes  very  serviceable  in  the  temporary 
control  of  hemorrhage  from  veins  and  capillaries,  is  the  elevated 
portion  of  the  bleeding  part.  This  is  especially  serviceable 
in  operation-  in  the  cranial  cavity  and  in  hemorrhage  from  the 
pelvic  organs. 

Permanent  Control. — Permanent  control  of  hemorrhage  is 
accomplished  by  numerous  plans,  all  of  which  at  times  fail. 

Pressure  on  a  bleeding  surface  with  a  sterile  sponge  or  swab, 
wet  or  dry.  will  usually  control  the  smaller  bleeding  vessels.  The 


344  PRINCIPLES   OF   SURGERY 

addition  of  intense  heat  or  cold  hastens  hemostasis.  Unless  the 
bleeding  can  be  controlled  by  such  means  in  a  very  short  tune, 
it  is  ordinarily  better  to  search  out  the  bleeding  points  and  ligate 
or  twist  them  at  once.  If  this  cannot  be  done,  one  is  justified  hi 
mopping  the  bleeding  surface  with  swabs  dipped  in  boiling  water. 
This  plan  is  all  the  more  feasible  if  the  wound  is  of  such  a  nature1 
that  healing  per  primam  is  either  impossible  or  undesirable,  as  in 
cystotomy  or  prostatectomy.  However,  the  employment  of  this 
method  does  not  necessarily  prevent  primary  union. 

In  certain  instances  it  is  not  advisable  or  is  impossible  to 
ligate,  and,  at  the  same  tune,  severe  heat  or  cold  cannot  be  em- 
ployed, as,  for  example,  in  surgery  of  the  brain,  and  a  small  vein 
may  cause  endless  annoyance.  Frequently  such  a  hemorrhage  can 
be  controlled  by  cutting  a  small  bit  of  tissue  from  the  open  wound, 
muscle,  or  dura  mater  and  applying  it  over  the  bleeding  mouth. 
This  plan  very  materially  aids  in  securing  a  clot  that  efficiently 
controls  further  bleeding  (Gushing). 

Another-  plan  of  controlling  hemorrhage  by  pressure,  and  a 
very  efficient  and  satisfactory  one,  is  by  making  instrumental 
pressure  on  the  cut  end  of  the  vessel  with  hemostatic  forceps, 
which,  when  closed  tightly  and  left  in  situ  for  a  few  minutes,  will 
control  even  small  spurting  arteries;  or  by  the  angiotribe,  which 
crushes  the  vessel  proximal  to  the  point  of  severance  by  the 
employment  of  several  hundred  pounds'  pressure,  and  leaves  only 
the  connective-tissue  coats  unbroken,  but,  at  the  same  time,  each 
opposing  wall  firmly  glued  to  the  other.  The  bite  of  the  angio- 
tribe is  rather  wide,  and  vessels  as  .large  as  the  radial  may  be 
closed  by  this  means.  Blunk  has  recently  introduced  a  shearing 
hemostat,  which,  after  once  being  closed  on  a  moderately  large 
artery,  may  be  safely  removed,  for  it  severs  the  intima  and  media, 
but  not  the  adventitia,  and  a  clot  forms  between  the  curled-up 
ends  of  the  retracted  coats.  In  cases  of  deep  hemorrhage,  or 
hemorrhage  hi  parts  where  ligature  cannot  be  applied,  hemo- 
static forceps  may  be  left,  applied  to  the  vessels  indefinitely, 
until  all  danger  of  bleeding  is  past. 

Ligation. — The  most  widely  useful  plan  for  the  control  of  hem- 
orrhage, as  well  as  the  most  trustworthy,  is  the  closure  of  the 
bleeding  vessel  by  ligature,  and  it  should  be  the  rule  of  every 
operator  to  ligate  all  bleeding  points  unless  they  very  promptly 
respond  to  less  secure  means.  Ligatures  are  preferably  made  of 
catgut  or  kangaroo  tendon,  but  non-absorbable  materials  may  be 
used  for  the  large  vessels,  and  are,  indeed,  preferred  by  many 
surgeons.  The  objection  to  absorbable  material  is  the  possi- 
bility of  too  early  absorption  or  of  the  knot  slipping,  and  linen 
and  silk  are  objectionable  on  account  of  the  possibility  of  infec- 


HEMORRHAGE  345 

tion  and  the  establishment  of  a  sinus  or  fistula,  and  their  reten- 
tion in  the  tissues  as  a  foreign  substance.  If  a  wound  is  known 
to  be  infected,  or  even  probably  so,  it  is  preferable  to  employ 
absorbable  ligatures  as  well  as  sutures  for  subcutaneous  work; 
if  non-absorbable  ones  must  be  used,  they  may,  especially  in  am- 
putations, be  left  long  on  one  end,  and  the  thread  brought  out 
through  the  wound  so  as  to  afford  easy  removal  after  operation; 
tliis  is  particularly  important  in  those  cases  which  are  known  to 
be  infected. 

The  size  of  a  ligature  depends  on  the  size  of  the  vessel  to  be 
ligated.  The  smallest  bleeding  points  may  be  tied  with  No.  0 
or  No.  00  catgut,  and  the  largest  with  No.  2  or  No.  3.  The 
absorbability  of  the  ligature  should  be  determined  hi  the  same 
way,  the  smaller  vessels  being  tied  with  plain  gut  and  the  large 
ones  with  twenty-day  catgut,  if  catgut  can  be  used.  In  ligatmg 
blood-vessels  a  single  vessel  should  be  caught  and  tied,  and  no 
surrounding  tissue  should  be  embraced  in  the  ligature.  The 
vessel  should  be  tied  at  a  distance  from  its  cut  end  about  equal 
to  its  diameter.  If  a  satisfactory  hold  cannot  be  obtained  for 
the  ligature,  it  should  be  threaded  on  a  needle  and  passed  through 
an  adjacent  bit  of  tissue  as  close  to  the  vessel  as  possible  and  then 
tied.  There  is  no  rule  for  the  tension  of  ligatures,  except  that  they 
must  be  tied  tightly  enough  to  hold  their  place.  In  tying  larger 
vessels  it  is  better  to  pull  on  each  end  of  the  ligature  a  few  seconds 
while  tying  the  first  hitch,  to  give  it  time  to  become  firmly  em- 
bedded in  the  vessel  wall.  If  the  vessel  is  in  a  pedicle  which  is 
supported  by  an  assistant  while  the  operator  ties  his  ligatures, 
the  assistant  should  relax  his  tension  while  the  first  and  the 
second  hitches  are  being  drawn,  otherwise  there  is  danger  of 
slipping.  The  knot  to  be  used  in  tying  arteries  should  be  either 
the  reef  knot  or  the  surgeon's  knot.  If  the  arteries  are  hard  and 
ea-ily  cut  by  ligatures,  a  tape  ligature  should  be  selected,  or  the 
Ballanee-Ednnmds  ligature  should  be  used. 

Torsion. — This  plan  is  applicable  in  small  bleeding  vessels, 
such,  for  instance,  as  are  barely  too  large  to  be  controlled  by 
moderately  long  pressure.  It  should  not  be  employed  in  any  case 
when-  a  hematoma  would  cause  serious  complications;  that  is  to 
say,  the  plan  i-  unreliable,  and  should  not  be  employed  in  any 
artery  large  enough  to  spurt.  Torsion  is  made  by  clamping  the 
!  end-on  with  a  hemostat — a  second  narrow-bladed  forceps 
catcher  the  vessel  higher  up,  and  now  the  first  instrument  is 
turned  transversely  through  two  or  three  circles,  so  as  to  rupture 
the  inner  coats  of  the  vessel.  It  is  not  unusual  to  find  hemorrhage 
recurring  after  releasing  the  vessel  on  account  of  too  much  or  too 
little  torsion. 


346  PRINCIPLES   OF   SURGERY 

Cautery. — The  use  of  dry  heat  of  sufficient  intensity  to  cook  the 
tissues  is  an  ancient  and  efficient  hemostatic  plan.  It  is  unreliable 
hi  large  vessels,  especially  arteries,  for  it  would  manifestly  be  an 
easy  matter  to  dislodge  the  clot,  especially  in  the  presence  of 
infection  or  as  the  result  of  exertion  or  other  cause  of  increase  of 
blood-pressure.  It  is  to  be  employed  especially  in  bleeding  from 
small  arteries  and  veins  and  hi  diffuse  capillary  oozing,  especially 
such  as  is  found  coming  from  malignant  growths.  It  is  unneces- 
sary to  state  that  this  plan  is  contra-indicated  hi  cases  where 
healing  by  primary  union  is  expected;  however,  it  may  be  satis- 
factorily employed  here  hi  parts  of  the  wound  that  will  be  buried. 
Cauterization  can  be  more  satisfactorily  employed  if  the  part  to 


Fig.  67. — Torsion  for  control  of  hemorrhage  from  small  blood-vessels. 

be  burned  is  clamped.  In  this  manner  it  is  employed  as  a  very 
widely  favored  cure  for  hemorrhoids.  Stretching  of  the  cauter- 
ized surface  causes  recurrence  of  the  hemorrhage.  The  instru- 
ment used  to  control  hemorrhage  should  be  brought  to  a  red  heat, 
never  to  a  white  heat,  which  does  not  control  bleeding  satisfactorily. 
The  cautery  must  be  applied  to  the  bleeding  surface  until  the 
vessels  and  surrounding  tissues  are  cooked. 

Packing. — This  is  a  plan  for  the  permanent  administration  of 
pressure.  The  cavity  or  wound  may  be  filled  with  gauze  and 
sufficient  pressure  applied  to  stanch  serious  and  otherwise  un- 
controllable hemorrhage.  It  often  happens  that  a  deep  hemor- 
rhage occurs,  which  cannot,  under  the  most  favorable  circum- 
stances, be  checked  by  the  methods  heretofore  given,  or  under 


HEMORRHAGE  347 

favorable  circumstances,  when  no  other  convenient  plan  presents 
and  packing  becomes  the  sole  reliable  means.  In  case  packing  is 
done  for  hemorrhage,  it  should  be  left  in  position  for  several  days, 
often  as  long  as  a  week,  and  even  then  must  be  removed  most 
cautiously,  lest  recurrence  of  the  hemorrhage  be  produced.  In 
certain  irregular  or  inaccessible  small  cavities  hemorrhage  may 
be  checked  by  plugging  the  outlets  and  allowing  the  blood  to 
check  the  bleeding  by  its  own  pressure  when  the  cavity  is  filled. 
This  plan  is  employed  for  hemorrhage  from  the  nose,  by  pack- 
ing the  anterior  and  the  posterior  nares;  and  in  uterine  hemor- 
rhage by  packing  the  vagina.  In  certain  instances,  where  a  vessel 
< 'merges  from  a  small  canal  and  is  severed  so  close  to  the  outlet 
that  ligation  cannot  be  done,  a  wooden  peg  may  be  improvised 
ami  pushed  or  driven  into  the  canal.  I  have  been  compelled  to 
use  this  plan  on  a  patient  almost  exsanguinated  by  hemorrhage 
from  the  descending  palatine  artery.  This  plan  is  also  sometimes 
serviceable  in  controlling  hemorrhage  from  a  cut  or  sawn  bone 
surface. 

Drugs. — Chemical  agents  may  be  used  for  the  control  of  hem- 
orrhage from  small  vessels,  but  they  are  not  generally  employed 
to  a  great  extent;  the  plan,  however,  is  very  serviceable  on  occa- 
sion. The  drugs  are  astringent,  cause  coagulation  or  contract  the 
blood-vessels,  and  render  the  tissues  surrounding  the  bleeding 
vessels  anemic.  Monsell's  solution  and  alumnol  represent  the 
tii-t  t\vi»  of  the  group  and  adrenalin  chlorid  the  last  one.  They 
an-  not  to  be  thought  of  in  violent  hemorrhage.  Sometimes 
adrenalin  chlorid  is  injected  into  the  tissues  in  conjunction  with  a 
cocain  solution,  as  it  increases  the  anesthetic  property  of  the 
cucain  and  produces  anemia  so  complete  that  only  vessels  of  con- 
-iderahle  >ixe  will  bleed  at  all,  or  it  is  applied  to  the  mucous  mem- 
brane to  prevent  hemorrhage,  but  the  disadvantage  of  these  pro- 
cedures is  that  subsequent  hemorrhage  is  likely  to  occur  from 

Ve— els   -it   completely    coii>t  rict  ei  I    \<\     the   adrenalin    that    ll<>    Mood 

wa>  left  within  their  lumen  near  the  incision  to  clot;  hence,  when 
relaxation  occurs  there  is  nothing  to  prevent  bleeding  into  the 
wound. 

Hemorrhage  from  bone  is  often  not  amenable  to  any  of  the 
preceding  plans  of  control.  If  the  cut  surface  of  the  bone  is  thin 
and  the  bone  is  flat,  as  in  cranial  bones,  the  bleeding  may  be  con- 
trolled l.y  crushing  the  thickness  of  the  bone  at  the  bleeding  point 
with  a  Luer  or  other  forceps.  Thi-  compresses  the  vessels  by 
forcing  small  fragments  of  hone  against  them  from  either  side. 
In  cases  where  this  cannot  be  done,  or  where  it  fails,  the  proper 
employment  of  bone-wax  i<  most  satisfactory  (Kocher).  The 
wax  is  pressed  forcibly  against  the  bleeding  surface  of  the  hone 


348  PRINCIPLES   OF   SURGERY 

after  sponging  as  dry  as  possible  and  is  left  in  situ.  It  is  super- 
fluous to  state  that  this  wax  must  be  sterile. 

Hemophilia. — One  of  the  most  alarming  misfortunes  that 
befalls  the  surgeon  is  to  learn  after  he  is  under  way  in  an  opera- 
tion that  his  patient  is  a  hemophiliac.  It  is  serious  enough  to  be 
confronted  by  an  uncontrollable  accidental  hemorrhage  of  this 
kind.  After  all  the  known  plans  have  been  tried,  failure  may 
result,  and  death  ensue  from  an  insignificant  wound.  The  larger 
vessels  can,  of  course,  be  controlled,  but  the  bleeding  continues 
to  come  from  everywhere,  small  but  constant.  So  hemophilia 
may  be  accepted  as  a  most  positive  centra-indication  to  surgery. 
If  surgery  is  necessary  to  save  life  a  preliminary  treatment  should 
be  given  to  increase  the  coagulability  of  the  blood.  This  treat- 
ment is  unsatisfactory  in  many  instances,  and  consists  in  the 
administration  of  calcium  salts,  especially  the  lactate,  in  full 
doses  for  some  weeks.  A  few  recent  cases  would  indicate  that 
direct  transfusion  of  blood  from  a  near  relative  whose  blood  is 
normal  is  a  most  reliable  treatment,  and  one  whose  duration  at 
any  rate  extends  over  some  months.  In  cases  where  bleeding  has 
reached  the  danger  point,  not  only  is  the  hemophilia  corrected, 
but  the  anemia  is  at  the  same  time  improved.  Still  more  recently 
the  injection  of  horse-serum  has  proved  to  be  very  efficacious  hi 
hemophiliacs. 

Secondary  Hemorrhage. — Subsequent  to  an  injury  and  con- 
sequent upon  it  or  some  accident  or  complication,  but  not  imme- 
diately, a  hemorrhage  may  take  place;  this  is  secondary  hemor- 
rhage. Its  chief  danger  lies  in  the  fact  that  it  may  occur  with- 
out the  knowledge  of  either  the  patient  or  his  attendants,  and 
become  alarming  before  its  presence  is  discovered.  Secondary 
hemorrhage  usually  occurs  as  the  result  of  displacement  of  ter- 
minal thrombi,  separation  of  sloughs  hi  contused  and  lacerated 
wounds,  traumatism  done  to  wounds  whose  vessels  are  insecurely 
blocked,  as,  for  example,  stretching  of  the  anus  after  clamp  and 
cautery  operation  for  hemorrhoids,  and  to  necrosis  of  the  vascular 
walls  from  pressure  or  otherwise. 


CHAPTER    XXI 
SHOCK 

IN  the  present  state  of  our  knowledge  of  the  physiology  of 
shock  it  is  impossible  to  define  it  accurately,  and,  one  may  say, 
to  differentiate  scientifically  from  closely  allied  conditions.  It 
becomes  necessary,  therefore,  to  accept  the  term  as  representa- 
tive of  a  group  of  phenomena  which  ensue  with  variable  intensity 
upon  receipt  of  injury. 

Cause. — The  appearance  of  shock  and  the  intensity  of  it  are 
very  variable.  Factors  which  in  one  individual  produce  violent 
shock  cause  no  manifest  change  in  another.  So  that,  while  ex- 
traneous influences  play  a  very  important  part  in  the  production 
of  shock,  the  general  conditions  and  idiosyncrasies  of  the  indi- 
vidual and  the  part  affected  by  those  extraneous  influences,  espe- 
cially its  sensory  nerve  supply,  all  contribute  their  part  to  the 
symptom  complex.  It  may  be  accepted  at  this  point  that  shock 
is  a  reflex  disturbance,  rendered  possible  by,  and  established 
through,  the  function  of  afferent  nerves  or  by  agents  capable  of 
acting  similarly  on  nerve  centers.  The  causes  of  shock  may  be 
divided  into  predisposing  and  exciting. 

Predisposing  Factors. — One  of  the  most  frequent  predisposing 
or  associate  causes  of  shock  is  hemorrhage.  It  has  been  long 
established  in  operative  surgery  that,  other  things  being  equal, 
the  patient  who  bleeds  is  much  more  susceptible  to  shock  than  one 
in  whom  all  the  vessels  possible  are  spared  and  all  loss  of  blood 
from  severed  vessels  is  checked  promptly  and  efficiently;  likewise, 
patients  who  have  recently  suffered  a  severe  hemorrhage  develop 
and  succumb  to  shock  much  more  readily  during  operation.  This 
additional  fact  must  be  borne  in  mind,  namely,  that,  although  the 
loss,  of  blood  during  or  preceding  may  be  so  insignificant  as  per  se 
to  cause  no  perceptible  change  in  the  blood-pressure  or  in  the 
general  feeling  of  the  patient,  still,  when  the  exciting  causes 
of  shock  are  added,  every  drop  of  blood  that  has  escaped  must 
be  considered  a  distinct  loss  in  his  resistance  to  shock. 

Anemia  and  Malnutrition. — Patients  who  are  undernourished, 
whether  a>  a  consequence  of  improjx'r  or  insufficient  feeding  or 
who  suffer  either  a  primary  or  a  secondary  anemia,  are  more  sus- 
ceptible to  the  agencies  which  produce  shock.  Hence,  except 
when  imperative,  surgical  procedures  likely  to  be  attended  with 
shock  should  be  postponed  until  the  general  condition  can  be  im- 

Ml 


350  PRINCIPLES   OF   SURGERY 

proved;  and  if  surgery  is  immediately  imperative  all  necessary 
precautions  should  be  observed  prior  to  and  during  the  opera- 
tion. 

Infection. — The  absorption  of  bacterial  products,  whether  it 
be  in  case  of  an  acute  inflammatory  process,  a  general  infection, 
or  an  auto-intoxication,  renders  the  individual  less  resistant  to 
shock.  This  fact  should  be  especially  impressed  hi  reference  to 
extensive  inflammations.  It  is  thought  that  the  severe  shock  con- 
sequent upon  extensive  burns  is  partially  attributable  to  the 
poisons  absorbed  from  the  dead  or  crippled  tissues. 

Anesthesia. — It  should  be  practically  accepted  that  anes- 
thetics favor  the  production  of  shock  somewhat,  and  that  if  they 
are  continued  long  in  full  dosage  they  may  of  themselves  produce 
shock,  and,  if  continued  for  sufficient  duration,  death.  Chloro- 
form is  more  prone  to  cause  or  favor  shock  than  ether;  the  latter 
drug,  however,  is  not  free  from  this  danger.  The  administration 
of  abundant  supplies  of  oxygen  during  anesthesia  reduces  the 
danger  from  shock.  Hence,  the  so-called  open  or  drop  method 
of  administration,  or  one  in  which  the  anesthetic  vapor  is  mixed 
with  oxygen  or  air  by  special  apparatus,  is  preferable  to  the  old 
smothering  methods.  Local  anesthesia  as  ordinarily  employed 
probably  contributes  little,  if  anything,  toward  the  causation  of 
shock.  Its  proper  use  in  blocking  large  nerves  supplying  the 
field  of  operation,  either  hi  conjunction  with  or  hi  the  absence  of 
general  anesthesia,  unmistakably  reduces  the  liability  to  shock. 

Cold. — Reduction  of  the  body  temperature  by  exposure  to  cold 
renders  the  body  much  more  susceptible  to  shock.  Not  only  so, 
but  the  exposure  of  raw  surfaces  or  of  serous  cavities  and  their 
contents  to  the  atmosphere  adds  materially  to  the  chances  of 
shock,  and  will  often  certainly  produce  it,  when  the  operation  of 
itself  would  ordinarily  have  no  such  effect.  Even  when  the  tem- 
perature of  the  operating  room  is  equal  to  that  of  blood  hi  the 
internal  organs,  the  occurrence  of  evaporation  materially  reduces 
the  heat  of  such  wounds  and  surfaces.  Hence,  large  dissections, 
especially  if  they  are  to  be  prolonged,  should  be  covered  with 
moist,  hot  towels,  and  the  serous  linings  of  the  large  cavities 
should  be  exposed  only  sufficiently  to  admit  of  easy  performance  of 
work.  Viscera  should  not  be  held  out  of  their  proper  cavities  longer 
than  is  absolutely  necessary,  and  when  the  necessity  arises  the 
most  assiduous  protection  should  be  afforded. 

Exciting  Cause. — It  is  reasonable  to  suppose  that  any  of  the 
predisposing  factors  of  shock  above  mentioned,  if  pushed  to  the 
extreme,  might  produce  a  more  or  less  intense  degree  of  shock. 
However,  as  we  at  present  conceive  it,  shock  is  produced  by  an 
excessive  stimulation  of  afferent  nerves.  From  this  statement 


SHOCK  351 

two  conclusions  are  to  be  drawn,  namely,  first,  that  the  more 
abundant  this  nerve  supply  for  a  given  part,  the  greater  the  like- 
lihood of  shock  arising  from  interference  with  it,  and,  second,  the 
nature  of  the  interference  is  more  unfavorable  the  more  it  stimu- 
lates afferent  impulses.  If  the  nerve  connection  between  the  field 
of  irritation  be  previously  severed  or  blocked  by  infiltration  anes- 
thesia, the  possibility  of  shock  is  removed  or  its  intensity  reduced. 
In  practical  surgery  shock  is  seen  most  frequently  as  the  result 
of  injuries,  in  which,  if  there  is  continued  or  severe  hemorrhage, 
the  symptoms  become  alarming  and  may  often  produce  death; 
large  dissections  are  capable  of  producing  violent  shock,  and  their 
liability  to  do  so  is  increased  by  rough  handling,  tearing,  or  bruis- 
ing the  tissues.  Hence,  the  necessity  in  such  cases  of  cutting 
the  tissues  rather  than  tearing  them,  of  clamping  and  ligating 
blood-vessels  only,  rather  than  enclosing  large  masses  of  muscle 
and  possibly  severed  ends  of  nerves.  The  danger  of  continuing 
the  anesthetic  a  little  longer  and  of  protracting  the  operation  is 
far  outweighed  by  careless  handling  of  the  tissues  and  unnecessary 
hemorrhage.  The  area  of  irritation  is  likewise  to  be  considered; 
this  is  best  illustrated  by  the  statement  that  a  superficial  burn 
produces  as  much  shock  as  a  deep  one;  a  burn  on  a  surface  well 
supplied  with  nerves  more  than  on  one  poorly  supplied;  a  large 
area  proportionately  greater  shock  than  a  small  one.  Besides 
actual  gross  injury  to  tissues,  other  factors,  to  be  sure,  of  a  similar 
nature  may  cause  it;  as  an  illustration  I  may  cite  the  certainty 
with  which  traction  on  the  mesentery  is  followed  by  it.  The 
regions  most  likely  to  produce  shock  when  unduly  manipulated  are 
the  cranial  cavity  (i.  e.,  after  incision  of  the  dura),  the  parietal 
peritoneum,  and  the  parietal  pleura.  The  visceral  reflections  of 
these  nieniliranes  do  not  contain  sensory  nerves.  In  dissections 
of  the  extremities  and  in  amputations  the  most  important  factor 
is  severance  of  the  large  nerves  or  irritation  of  their  branches; 
tiaumatism  to  the  voluntary  muscles  also  produces  shock.  The 
pathologic  com  lit  ions  which  most  frequently  produce  shock  are  in- 
testinal  perforation-,  intestinal  obstruction,  and  acute  pancreatitis. 
Physiology  of  Shock. — The  exact  nature  of  shock  is  unknown, 
and  it  is  difficult  to  differentiate  it  physiologically  from  collapse 
ami  syncope.  It  is  not  quite  certain,  so  far,  that  an  exact  measure 
of  shock  i>  in  our  possession.  Reduction  of  blood-pressure  is  the 
ino-t  reliable  means  for  determining  the  decree  of  shock  when  it 
i-  shock  we  are  dealing  with;  l>ut  it  is  more  than  the  reduction  of 
arterial  tension,  for  this  phenomenon  is  seen  in  practice,  and 
experimentally  produced,  without  shock.  Likewise  in  circum- 
stances likely  to  produce  shock  the  only  safe  means  of  antici- 
patinn  it  i-  a  clo>»-  observation  <rf  Mood-pressure. 


352  PRINCIPLES   OF   SURGERY 

In  collapse  and  syncope,  while  either  of  them  may  rarely  prove 
fatal,  recovery  usually  takes  place  in  a  very  short  time;  so  that  if 
in  the  manner  of  causation  they  are  similar  to  shock  they  differ 
materially  in  their  duration.  In  shock  there  is  a  persistent  and 
protracted  reduction  in  blood-pressure  which  may  last  for  days, 
and  which  rarely  disappears  short  of  several  hours.  The  cause 
seems  to  be  an  inhibition  of  the  inhibitory  centers  for  the  heart 
and  of  the  vasoconstrictors.  The  heart  centers  may  be  affected 
in  shock,  causing  an  increase  in  its  rate,  with  no  associate  involve- 
ment of  the  vasoconstrictor  centers,  but  the  latter  are  never  in- 
volved independently  of  the  former  (Howell). 

Symptoms. — The  pulse  becomes  rapid  and  the  blood-pressure 
low,  sometimes  as  low  as  30  to  40  mm.  of  mercury.  Since  the 
normal  blood-pressure  varies  so  widely,  one  can  judge  of  the 
approach  or  the  presence  of  shock,  especially  the  less  severe  cases, 
only  by  comparison  with  the  normal  blood-pressure  of  the  indi- 
vidual case.  There  is  no  standard  blood-pressure  limit,  on  one 
side  of  which  the  index  would  show  the  presence,  while  on  the 
other  it  showed  the  absence  of  shock.  The  temperature,  as  a  rule, 
is  subnormal,  but  this,  too,  is  likely  to  mislead,  for  if  the  tempera- 
ture were  much  above  normal  at  the  outset  it  might  not,  even 
when  reduced  by  the  appearance  of  shock,  immediately  drop  so 
far  as  normal.  The  skin  is  pale  and  cool  and  clammy.  Respira- 
tion is  slow  and  shallow.  The  reflexes  are  subnormal  or  wholly 
disappear.  The  mind  is  clear;  delirium  does  not  occur;  the  indi- 
vidual seems  to  be  stunned  and  is  incapable  of  quick  mental  ac- 
tivity. 

Operation  During  Shock. — In  cases  which  have  been  sub- 
jected to  violence  and  are  in  shock  the  rule  is  very  definite  that 
it  is  better,  nay,  imperative,  not  to  operate  until  recovery  from 
the  shock  is  complete,  provided  that  the  operation  is  not  necessary 
for  immediate  removal  of  factors  which  progressively  increase  the 
shock;  for  example,  shock  is  no  centra-indication  to  operation  in 
case  the  injury  is  associated  with  an  uncontrollable  hemorrhage, 
and  in  those  pathologic  conditions  likely  to  be  attended  by  shock 
it  is  necessary  to  operate  at  the  earliest  moment.  The  longer  one 
postpones  the  operation  for  intestinal  perforation,  strangulated 
hernia,  and  acute  general  peritonitis,  the  greater  the  shock,  in- 
tensified evidently  by  absorption  of  toxins,  and  the  smaller  the 
chance  of  recovery.  However,  when  these  conditions  are  asso- 
ciated with  shock,  only  the  judgment  that  comes  of  wide  expe- 
rience can  guide  the  surgeon  from  interference  in  hopeless  cases. 

Prognosis. — The  outcome  even  of  severe  cases  of  shock  is,  on 
the  whole,  favorable  if  it  be  uncomplicated  by  hemorrhage  and 
virulent  and  extensive  infection.  When  the  patient  begins  to  show 


SHOCK  353 

evidence  of  reaction  it  is  an  indication  that  he  will  recover,  unless 
additional  shock  is  produced  by  operative  or  manipulative  work. 
An  example  of  this  may  be  given — when  a  severe  injury,  such  as  a 
compound  fracture,  is  done  and  shock  is  produced,  moving  the 
patient  over  a  long  rough  journey,  or  manipulation  to  determine 
the  exact  nature  of  the  fracture,  may  prove  fatal. 

Treatment  of  Shock. — The  most  successful  surgeons  devote 
their  attention  especially  to  the  prevention  of  shock  hi  their 
operative  work;  as  little  alarm  should  be  produced  by  the  prepara- 
tion as  possible,  especially  when  the  work  must  be  done  in  the 
home,  for  there  is  no  doubt  that  fright  or  excitement  may  at  least 
favor  shock ;  if  necessary  a  dose  of  morphin  or  scopolamin-morphin- 
hyoscin  should  be  administered  an  hour  or  an  hour  and  a  half 
prior  to  beginning  anesthesia. 

The  anesthetic  (preferably  ether)  should  always  be  admin- 
istered by  skilful  hands  and  only  in  sufficient  quantity  to  meet  the 
demands,  increasing  the  amount  when  sensitive  tissues  are  to  be 
cut,  reducing  to  a  minimum  when  they  are  past.  Easy  handling 
of  the  tissues  is  necessary;  cutting,  never  tearing,  them  hi  the 
larger  operations.  Control  of  hemorrhage  must  be  done  with 
the  most  scrupulous  care  and  completeness,  particularly  in  long 
operations;  protection  of  raw  surfaces  and  serous  cavities  from 
exposure  to  the  atmosphere  and  from  drying,  and  the  avoidance 
of  chilling  the  body  surface  by  allowing  the  patient  to  remain 
saturated  with  solutions  during  operation,  must  be  assiduously 
observed.  Constant  supervision  of  the  patient's  general  condi- 
tion will  often  save  the  surgeon  from  unfortunate  results  by 
seeing  the  approach  of  shock  sufficiently  early  to  do  a  two-time 
operation.  This  is  particularly  true  of  surgery  of  the  brain. 

The  treatment  of  shock  is  very  important,  and  should  be 
thoroughly  mastered,  as  the  need  for  sound  judgment  in  its 
application  may  arise  at  any  time,  and  very  wide  deviation  from 
the  proper  reiriuie  may  prove  fatal.  The  first,  and  perhaps  the 
most  important,  lesson  to  be  learned  is  that  stimulants  are  con- 
tra-indieated:  the  inhibitory  centers  of  the  heart  are  out  of  com- 
mi-- ion.  and  the  heart,  therefore,  runs  away.  The  patient  should 
lie  placed  in  an  inclined  position,  head  downward,  or,  if  this  is 
inipn— ible,  he  should  at  least  be  allowed  to  occupy  the  horizon- 
tal poHtion  and  the  head  should  not  be  raised  for  any  pur- 
pH-r.  Artificial  heat  should  be  applied  abundantly  at  the  car- 
lie.- 1  moment  and  maintained;  \\\«}\  temperature  of  the  atmo- 
sphere should  not  cause  one  to  forget  this.  The  legs,  arms,  and 
abdomen  >h<>uld  be  bandaged  firmly  enough  to  prevent  accu- 
mulation of  blood  hi  the  vessels  and  to  force  it  on  toward  the 
heart.  If  the  put  lent  is  in  pain,  or  restless,  sufficient  morphin 

23 


354  PRINCIPLES   OF   SURGERY 

should  be  administered  hypodermically  to  relieve  the  symptoms. 
A  moderate  dose  of  it  is  not  amiss  in  any  case  of  shock.  The  only 
other  drug  that  seems  to  be  of  much  importance  is  adrenalin  chlorid, 
of  which  10  to  20  minims  of  the  1: 1000  solution  may  be  injected 
hypodermically,  and  repeated  when  found  necessary.  The  injec- 
tion of  normal  salt  solution  subcutaneously  or  intraveneously  is 
positively  indicated  when  shock  has  been  associated  with  hemor- 
rhage, and,  although  it  does  not  appear  necessary  from  animal 
experimentation,  it  seems  unquestionably  to  be  of  great  advantage 
in  clinical  work  when  there  is  no  hemorrhage.  In  the  more  severe 
cases  the  intravenous  method  is  preferable. 

Crile  has  devised  a  pneumatic  suit  to  cover  the  legs  and  ab- 
domen, by  means  of  which  equable  pressure  may  be  produced 
advantageously. 

As  little  disturbance  of  the  patient's  rest  and  comfort  as  pos- 
sible should  be  done,  and  when  such  disturbance  becomes  neces- 
sary the  greatest  precaution  should  be  observed  to  avoid  causing 
pain. 


CHAPTER    XXII 
WOUNDS 

A  WOUND  is  a  severance  of  soft  tissues  inclusive  of  their 
covering  membrane. 

Infection. — It  must  be  assumed  that  practically  every  wound 
produced  on  surfaces  which  have  not  been  sterilized  is  infected, 
and  this  fact  must  be  borne  in  mind  as  of  prime  importance  in 
treatment.  The  tissues  might  be  able  to  overcome  the  infection 
and  thus  escape  inflammation,  suppuration,  and  failure  to  heal  by 
fir-t  intention.  This  has  been  placed  by  many  hi  the  category  of 
poisoned  wounds,  but  it  seems  to  me  better  to  reserve  that  term 
for  a  more  restricted  group  of  wounds. 

Characteristics. — Every  wound  has  certain  common  char- 
acteristics. First,  there  is  severance  of  the  tissues,  frequently  de- 
duction or  removal  of  parts  of  tissue.  Hemorrhage  is  usually 
present,  and  is  unmistakable  evidence  that  the  blood-vessels 
are  uncovered  and  opened;  it  remains  true,  however,  that  certain 
wounds  do  not  produce  hemorrhage,  and  in  these  there  is,  instead, 
a  discharge  of  lymph,  usually  in  small  quantity.  This  class  of 
wounds  embraces  Ihose  inflicted  upon  non-vascular  tissues,  as, 
for  example,  the  cornea,  superficial  wounds  of  the  tegument 
which  are  not  deep  enough  to  enter  even  the  surface  capillaries, 
hut  have  penetrated  through  the  protective  epithelium,  and  wounds 
made  superficially  by  small  round  instruments,  which  when 
withdrawn  permit  the  closure  of  the  opening  and  prevent  bleed- 
ing. Pain  is  the  third  common  symptom  of  wounds.  It  varies 
with  the  site,  the  manner  of  production,  and  the  nature  of  the 
wound.  Pain  during  the  production  of  a  wound  is  more  severe 
when  produced  slowly  and  by  dull  instruments;  that  from  tearing 
is  worse  than  that  from  cutting.  Of  course,  pain  is  more  intense 
in  those  parts  well  supplied  with  sensory  nerves. 

Classification.  Wounds  arc  subdivided  into  incised,  punctured, 
}><  in /rut i  mi,  fn-rforiiting,  contused,  lacerated,  brush  wounds,  gunshot 
wounds,  and  ftoixoned  wounds. 

I  in- />///  11  ounds. — An  incised  wound  is  one  made  by  a  sharp, 
cutting  in-trument.  They  hleed  freely,  are  painful,  and,  as  a  rule, 
•rape.  They  gape  more  readily  when  made  in  certain  directions 
than  in  others,  as  has  l>een  lieautifully  shown  l>y  Kocher.  Gap- 
ing is  also  worse  in  wounds  that  extend  deeply  into  the  tis- 


356  PRINCIPLES   OF   SURGERY 

sues  than  in  superficial  wounds;  it  is  also  worse  in  those  produced 
in  parts  whose  integument  has  a  superficial  panniculus  carnosus, 
and  there  is  a  marked  disposition  in  such  parts  for  the  skin  edges 
to  roll  under  when  approximated;  gaping  is  wider  in  wounds 
through  the  scalp,  when  they  extend  through  the  occipitofrontalis 
or  its  aponeurosis,  provided  the  line  of  separation  lies  transverse 
to  the  direction  of  the  fibers.  The  edges  of  an  incised  wound  are 
smooth  and  clean  cut,  and  do  not  show  evidence  of  tissue  destruc- 
tion. Incised  wounds  are  the  most  favorable  for  treatment  and 
the  most  dangerous  from  a  standpoint  of  hemorrhage. 

Punctured  Wounds. — Punctured  wounds  are  produced  by  elon- 
gated, pointed  instruments  which  may  or  may  not  have  a  cutting 
edge.  The  most  frequent  example  of  this  wound  is  that  produced 
by  nails.  It  has  a  greater  depth  than  diameter.  The  point  of 
entrance  may  appear  as  a  slit  or  short  incised  wound  if  made  by  a 
cutting  instrument,  or  as  an  irregular  or  roundish  opening.  There 
is  no  destruction  of  tissue.  There  may  be  slight  bleeding,  but  it  is 
usually  very  slight  unless  a  large  vessel  has  been  cut.  Pain  is  not 
marked  on  account  of  the  small  extent  of  injury  to  the  integu- 
ment. Occasionally  a  punctured  wound  is  seen  in  which  the  in- 
strument used — e.  g.,  a  dagger — is  moved  back  and  forth  after 
penetrating  the  tissues,  so  that,  without  increasing  the  wound 
in  the  skin,  an  extensive  injury  is  done  to  the  deeper  structures. 
Wounds  of  this  type,  however  produced,  are  not  called  punc- 
tured wounds  if  they  enter  a  normal  body  cavity. 

Penetrating  Wounds. — Penetrating  wounds  are  those  that 
enter  a  normal  body  cavity.  They  may  be  produced  by  any 
means  whatsoever,  incision,  puncture,  or  gunshot;  their  char- 
acteristic feature  is  the  opening  of  a  cavity,  not  their  method  of 
production.  The  cavities  most  concerned  with  such  wounds  are 
the  abdomen,  pleural  cavity,  and  the  cranium. 

Perforating  Wounds. — Perforating  wounds  are  entirely  similar 
to  penetrating,  except  that  they  have  an  entrance  to  and  an  exit 
from  the  affected  cavity.  The  causative  agent  passes  into,  through, 
and  out  of  the  cavity.  The  danger  of  penetrating  and  perforating 
wounds  consists  in  the  fact  that  infection  may  be  introduced 
into  a  large  serous  cavity,  the  viscera  may  be  injured,  and  con- 
cealed hemorrhage  may  take  place,  sometimes  so  rapidly  that 
death  is  caused  in  a  short  while  from  this  cause  alone. 

Contused  Wounds. — Contused  wounds  are  produced  by  dull 
instruments  violently  applied,  such  as  a  club,  or  by  falls  in  which 
the  body  is  thrust  against  a  flat  or  rounded  surface.  In  contused 
wounds  there  is  wound  plus  contusion  of  the  adjacent  tissues. 
The  edges  of  the  wound  are  uneven,  bruised,  swollen,  discolored, 
and  often  abraded,  and  instead  of  retracting  lie  touching  each 


WOUNDS  357 

other  or  overlap.  Hemorrhage  is  not  marked;  the  manner  of  pro- 
duction crushes  or  tears  the  blood-vessels,  so  that  they,  even  when 
large,  often  do  not  bleed  long  or  profusely.  Owing  to  injury  of  the 
tissues  and  subsequent  sloughing,  however,  secondary  hemorrhage 
is  more  likely  to  take  place  in  these  than  in  any  other  type  of 
wound.  Pain  is  not  marked.  Infection  develops  more  readily  in 
contused  wounds  than  in  any  other  type  on  account  of  extensive 
devitalization.  In  case  contused  wounds  are  produced  on  dense 
tissues,  such  as  the  scalp,  it  is  frequently  difficult  to  distinguish 
them  from  an  incised  wound.  Pressure  produced  on  the  scalp 
IK -t\veen  the  two  opposing  forces  bursts  it. 

Lacerated  Wounds. — Lacerated  wounds  are  caused  by  tearing, 
am  1  :ire  produced  by  such  instruments  as  saws,  shredding  machines, 
cog-wheels,  and  such  like.  The  edges  are  irregular,  but  less  likely 
to  be  swollen  and  discolored  than  in  contused  wounds;  they  are 
otherwise  similar  to  contused  wounds.  The  tissues  may  hang  in 
si  i reds  and  flaps.  Secondary  hemorrhage  is  less  likely  to  occur 
than  in  contused  wounds. 

Brush  Wounds. — Brush  wounds  are  produced  by  the  rapid 
movement  of  the  tissues  over  a  rough  surface  or  vice  versa.  They 
are  usually  produced  by  moving  belting,  by  sliding  down  a  rope, 
or  by  ei  nery  wheels.  The  tissues  are  literally  ground  away.  They 
are  usually  superficial,  often  no  more  than  an  abrasion,  but  occa- 
sionally extend  to  the  muscles  and  tendons.  They  do  not  bleed 
much,  but  are  very  painful. 

Gunshot  Wounds. — Gunshot  wounds  are  produced  by  missiles 
from  firearms,  which  are  the  most  frequent  cause.  The  term  is 
made  to  embrace  also  all  wounds  produced  by  bodies  thrown  by 
explosives. 

The  peculiar  interest  attaching  to  this  subdivision  of  wounds 
gr<  >\vs  out  of  the  fact  that  the  agent  causing  the  "wounds  may  be 
hurled  in  the  tissues  or  pass  through  them;  the  peculiar  trauma 
produced  by  its  passage  through  the  tissues,  the  possibility  of 
injury  to  various  structures  in  its  course,  the  danger  of  concealed 
hemorrhage  or  of  hemorrhage  from  inaccessible  vessels,  the  possi- 
bility of  particles  of  clothing  passing  into  the  wound  with  the 
mi— ile,  and  the  danger  of  infection. 

The  nature  of  gunshot  wounds  is  varied.  They  range  from 
a  small  ami  insignificant  wound,  produced  by  powder  grains 
being  driven  into  or  through  the  tegument-  and  superficial  burns, 
to  the  most  extrn-ive  and  dangerou.-  mangling  of  the  tissues; 
from  a  simple  puncture  or  perforation  of  soft  parts  to  the  most 
horrible  shattering  of  bones  or  extensive  perforation  of  viscera. 
Large  pieces  of  flesh,  occasionally  an  entire  extremity,  may  be 
blown  or  torn  away,  or  a  more  serious  injury  done,  with  no  other 


358 


PRINCIPLES    OF   SURGERY 


Fig.  68. — Gunshot  wound  of  cranium  showing  wound  of  entrance  of  44-caliber 

ball. 


Fig.  69. — Same  as  Fig.  68,  showing  wound  of  exit  and  exposed  brain.     These 
photographs  were  made  three  weeks  after  injury. 

evidence  than  a  small  wound  of  entrance  and  of  exit.    The  imme- 
diate damage  done  in  gunshot  wounds  depends  on  the  size  of  the 


WOUNDS 

mi— ile,  its  shape,  its  velocity,  its  weight,  and  its  resistance  to 
impact  and  the  kind  of  weapon  it  is  thrown  from.  The  remote 
effect  depends  on  the  tissues  affected  by  the  wound  and  the 
nature  of  the  bacteria,  if  any  are  carried  into  the  wound  at  the 
time  or  subsequently. 

Slowly  moving  missiles  produce  contusions,  lacerations,  con- 
tused wounds,  and  fractures,  and  are  more  likely  to  do  so  if  they 
are  large  and  rough.  If  these  large  projectiles  are  thrown  at  a 
high  velocity  they  tear  away  large  masses  of  tissue.  Small  pro- 
jectiles, which  produce  the  vast  majority  of  gunshot  wounds  both 


FIR.  70. — Clunshot  wound  of  entrance,  left  arm,  resulting  in  spreading 
traumatic  nan^reiie  and  death.  Tin-  skin  showed  no  evidence  of  the  presence 
of  naimrene.  Streptococci,  colon  bacilli,  and  numerous  saprophytes  were 
identified  from  cultures. 

in  civil  and  in  military  practice,  whether  thrown  at  a  moderate 
or  a  high  velocity,  enter  the  tissues.  For  a  missile  of  a  given  size 
the  factors  determining  the  nature  and  extent  of  the  wound  are 
the  velocity  and  hardness  of  the  missile.  Necessarily  the  main- 
tenance of  a  high  velocity  through  the  tissues  depends  on  the 
weight.  Soft  bullets  lose  their  shape  by  their  impact  against,  the 
ti-- ues,  and  in  their  further  passage  produce,  by  virtue  of  this 
change  in  -hape,  an  entirely  different  wound  from  those  pro- 
duced by  mi— iles  of  suflicient  ha  nine--  and  toughness  not  to  be 
so  altered.  A.irain.  th<  of  a  mi  — lie  through  the  tissues  at 

a  slow  velocity  damages  only  the  structure-  which  lie  in  its  path: 


360  PRINCIPLES   OF   SURGERY 

not  so  with  missiles  of  high  velocity,  for  they  not  only  affect  the 
structures  hi  the  track  of  the  wound,  but,  by  their  explosive  force, 
are  capable  of  doing  damage  to  tissues  in  surrounding  zones  of 
varying  diameter,  dependent  upon  the  nature  of  the  tissue  pene- 
trated and  the  velocity  at  the  tune  of  passage.  The  explosive 
force  of  bullets  is  easily  demonstrated  by  firing  a  high-velocity 
gun  carrying  jacketed  bullets  at  an  empty  vessel;  it  produces  a 
small  opening  at  the  points  of  entrance  and  exit.  But,  if  the  vessel 
is  filled  with  water  and  sealed  and  shot  hi  a  similar  manner,  it 
will  be  bursted  or  torn  into  fragments.  Hence,  as  in  the  long-range 
weapons,  the  velocity  diminishes  with  the  distance;  the  damage 
done  to  tissues  which  are  practically  solid  or  contain  fluid  by 
explosive  force  will  vary,  being  less  at  long  range  and  greatest  at 
close  range.  In  this  way  a  missile  may  penetrate  tissues  which 
are  not  of  vital  importance,  and  still  produce  death  by  the  ex- 
plosive violence  done  to  surrounding  structures. 

The  track  of  a  gunshot  wound  may  be  cylindric,  hi  which  the 
wound  of  entrance  and  the  wound  of  exit  are  of  practically  the 
same  size,  and  no  damage  done  to  tissues  lying  even  very  near  the 
course  of  the  missile.  The  wound  may  gradually  increase  hi 
diameter  along  the  course  of  the  missile,  due  to  its  having  been 
•flattened  against  the  tissues;  or  the  wounds  of  entrance  and  exit 
may  be  practically  of  the  same  appearance,  and  an  enormous 
destruction  of  tissue  be  produced  between  them,  by  the  ex- 
plosive action  of  jacketed  missiles  of  high  velocity. 

It  is  often  of  great  forensic  importance  to  differentiate  between 
the  wound  of  entrance  and  that  of  exit.  This  is  especially  true 
in  civil  practice;  the  weapons  employed  for  this  purpose  usually 
carry  soft  bullets,  which  renders  distinction  much  easier.  The 
wounds  produced  by  jacketed  bullets  often  cannot  be  distin- 
guished. The  wound  hi  the  skin  produced  by  a  bullet  striking 
at  right  angles  to  the  surface  is  usually  round,  and  apparently 
somewhat  smaller  than  the  diameter  of  the  ball  producing  it. 
They  are  sometimes  in  the  form  of  a  slit,  especially  if  situated  hi 
a  crease  of  the  skin.  If  the  impact  is  at  an  angle  J;-he  skin  on  the 
acute  side  is  abraded  and  beveled.  If  the  weapon  was  fired  at 
close  range,  the  surface  is  burned  or  blackened  and  shows  powder 
grams  driven  into  the  skin.  The  wound  of  exit  is  larger,  some- 
tunes  much  larger,  than  that  of  entrance,  is  often  fissured  at  its 
periphery,  everted,  and  more  ragged  than  the  wound  of  entrance. 
It  shows  no  evidence  of  powder  marks  or  of  burning.  There  may 
be  a  slight  amount  of  bleeding  from  either  wound;  it  is  severe  only 
when  large  vessels  have  been  opened,  but  if  these  vessels  lie  in  a 
large  cavity  or  in  a  loose  tissue  the  hemorrhage  will  reach  the  sur- 
face only  in  small  quantities  unless  the  wounds  are  unusually  large. 


WOUNDS  361 

Hemorrhage  is  not  constant  even  when  large  vessels  are  per- 
forated. I  have  seen  a  case  hi  which  both  popliteal  artery  and 
vein  were  perforated  with  no  hemorrhage;  the  result  was  an 
arteriovenous  aneurysm  and  gangrene  of  the  foot. 

The  degree  of  shock  produced  by  gunshot  wounds  depends 
on  the  tissue  injured  and  on  the  size  and  velocity  of  the  ball,  and, 
of  course,  on  the  amount  of  associated  hemorrhage.  Large  mis- 
silt  •>  produce  greater  shock  than  small  ones,  and  those  of  high 
velocity  produce  greater  shock  than  those  of  lower  velocity. 

The  course  of  a  missile  after  entering  the  body  can  only  be 
conjectured.  This  is  true  whether  there  is  both  a  wound  of  en- 
trance and  of  exit  or  only  one  of  entrance.  The  missile  is  deflected 
l»y  its  impact  against  the  tissues,  especially  the  bones,  and  often 
takes  a  course  at  great  variance  with  the  line  of  its  original  direc- 
tion. Even  the  skin  may  serve  to  deflect  the  ball,  and  though 
wounds  are  seen  which  by  the  relative  location  of  the  points  of 
entrance  and  of  exit  would  lead  one  to  believe  that  a  cavity  had 
been  perforated,  they  are,  in  fact,  little  deeper  than  the  subcutan- 
eous tissue.  Any  tissue  of  the  body  may  be  injured  by  the  passage 
of  a  bullet,  but  with  ordinary  arms  of  low  velocity  the  blood-vessels 
often  escape  miraculously  by  being  pushed  aside  by  the  passing 
ball.  However,  missiles  of  high  velocity  sever  the  vessels. 

Infection. — While  it  is  demonstrably  true  that  missiles  are  not 
sterile,  and  are  not  sterilized  by  being  shot  from  a  gun  and  passing 
through  the  atmosphere,  and  while  it  is  further  true  that  fre- 
quently small  bits  of  clothing  are  carried  into  the  wounds,  it  is  the 
rule  for  gunshot  wounds,  if  left  undisturbed,  to  run  a  non-inflam- 
matory course  and  to  heal  without  complications,  except  such  as 
grow  directly  out  of  the  structures  injured.  Most  of  the  infec- 
tion seen  in  gunshot  wounds  is  due  to  failure  to  protect  them  by 
antiseptic  or  aseptic  dressings  and  to  the  continued  practice  of  the 
antiquated  and  baneful  habit  of  probing  every  gunshot  wound, 
or  by  the  willingness  of  the  surgeon  to  yield  to  the  temptation 
to  undertake  the  removal  of  the  missile.  Most -cases  of  infection 
an-  <lue  to  this  cause;  and  this  is  not  all,  the  tissues  are  often  further 
injure.  1  l>y  such  practice. 

Poisoned  Wounds. — This  group  of  wounds,  formerly  stressed 
in  -urgical  texts,  has  come  to  be  of  slight  significance  from  a 
surgical  standpoint.  All  contaminated  wounds  may  be  subdi- 
vided into  two  groups.  Of  these  the  first  and  most  important 
is  infected  wounds,  the  nature  of  which  will  be  easily  understood 
by  a  study  of  the  chapters  on  Bacteriology,  Inflammation,  and 
Suppuration.  The  second  group  is  poisoned  wounds  proper, 
which  are  wounds  into  which  a  local  or  systemic  poison  is  in- 
jected at  the  time  of  infliction,  as  illustrated  by  the  bite  of  venom- 


362 


PRINCIPLES    OF   SURGERY 


ous  serpents  and  the  sting  of  insects.  Formerly,  wounds  inflicted 
by  weapons  which  had  been  contaminated  with  earth  contain- 
ing bacteria,  notably  tetanus  bacilli,  were  embraced  with  poisoned 
wounds,  but  patently  they  belong  to  the  first  group.  However, 
implements  of  warfare  which  carry  chemical  poisons  instead  of 
bacteria  produce  poisoned  wounds. 

The  characteristics  of  poisoned  wounds  depend  on  the  nature 
of  the  poison.  In  one  instance  they  are  entirely  local,  as  in  stings, 
and  in  another,  as  hi  the  bites  of  serpents,  they  may  be  both  local 
and  constitutional,  but  the  latter  is  the  more  important,  for  the 
mischief  is  done  by  the  general  effect  of  the  poisons  on  the  tissues. 

Surgical  Wounds. — Wounds  produced  by  the  surgeon  in  the 
routine  of  his  work  are  the  incised,  the  punctured  wound,  and 


Fig.  71. — Incised  wound  correctly  made. 

crushing  of  the  tissues;  the  latter,  which  may  be  described  as  an 
orderly  kind  of  contused  wound,  and 'is  usually  associated  with 
excision  of  the  tissues  distal  to  the  level  of  crushing,  occasionally 
is  necessary.  Occasionally  the  subcutaneous  tissues  are  torn 
properly  in  surgical  work,  but  this  plan  is  coming  more  and  more 
into  disrepute,  and  will  ultimately  be  employed  for  such  minor 
purposes  as  Hilton  recommended;  for  example,  in  opening  cer- 
tain abscesses. 

Incised  wounds  should  be  made  in  accordance  with  definite 
rules.  The  incision  should  always  be  made  in  a  plane  perpen- 
dicular to  the  surface,  otherwise  the  edges  will  be  beveled  and  the 
approximation  will  be  poorly  done.  The  ends  of  the  incision  should 
be  vertical,  as  nothing  is  gained  by  extending  the  cut  obliquely 


WOUNDS  363 

to  the  epithelial  covering.  The  incision  should  always  be  made 
rapidly  with  a  sharp  knife,  and  should  be  of  sufficient  length  to 
allow  easy  performance  of  the  work. 

Punctures  are  employed  for  the  localization  or  the  withdrawal 
of  pathologic  products  and  for  the  administration  of  drugs.  The 
instrument  may  be  inserted  directly  and  quickly  into  the  tissues, 
with  or  without  a  previous  puncture  of  the  skin  with  a  bistoury. 
If  there  is  danger  of  leakage  after  withdrawing  the  instrument, 
or  if  there  is  fear  of  infection  being  afterward  carried  from  the 
surface  along  the  tract  of  puncture,  a  safeguard  may  be  established 
by  sliding  the  skin  as  much  as  possible  to  one  side  and  then  punc- 
turing. When  the  work  is  finished,  and  the  skin  resumes  its 
normal  station,  the  opening  in  it  will  be  more  or  less  removed 
from  that  in  deeper  structures.  If  the  cavity  aspirated  is  under 
tension  and  leakage  is  feared,  insertion  of  the  instrument  ob- 
liquely is  the  best  safeguard. 

Crushing  the  tissues  in  surgery  is  done  for  two  purposes, 
namely,  the  control  or  prevention  of  hemorrhage,  as  seen  espe- 
cially in  the  clamp  and  cautery  hemorrhoid  operation,  and  for  the 
purpose  of  pressing  certain  tissues  out  of  the  way,  as  illustrated 
hi  appendectomy,  where,  by  the  employment  of  this  plan,  the 
mucous  membrane  is  forced  away  from  the  bite  of  the  clamp  and 
only  the  tougher  sterile  tissues  are  embraced  by  the  ligature. 

Treatment  of  Wounds. — The  first  step  in  the  treatment  of 
wounds  is  to  control  hemorrhage;  this  may  be  done  immediately 
by  temporary  means  until  facilities  for  permanent  control  can  be 
h;i«l.  The  loss  of  large  quantities  of  blood  is  so  detrimental  to 
healing  and  so  favorable  to  the  invasion  of  bacteria,  aside  from 
the  possibility  of  immediate  death,  that  hemorrhage,  if  at  all  free, 
should  be  controlled  even  at  the  sacrifice  of  other  important  sur- 
gical principles.  Hence,  when  bleeding  is  endangering  life  there 
may  be  no  time  (such  occasions  are  not  frequent)  for  preparation 
of  the  hands  or  sterilization  of  instruments;  so,  too,  the  presence 
of  even  severe  shock  is  an  urgent  indication  rather  than  a  contra- 
indication for  the  control  of  hemorrhage  at  any  risk  and  by  the 
most  rapid  and  direct  method.  After  the  hemorrhage  is  checked, 
one  may  postpone  further  procedures  until  the  patient's  condi- 
tion warrants  them.  In  operative  work  control  of  hemorrhage 
should  lie  made  immediately  before  or  after  its  appearance. 

The  >econd  step  in  the  treatment  is  to  cleanse  the  wound  and 
the  surrounding  field,  except,  of  course,  in  operative  work,  where 
previou>  preparation  renders  this  <tep  superfluous.  This  is  a  most 
important  item  in  wound  treatment,  and  one  that  is  too  often 
accepted  a-  impossible,  and,  on  the  other  hand,  one  often  ren- 
dered much  more  difiicult  on  account  of  the  various  unclean  ap- 


364 


PRINCIPLES   OF   SURGERY 


plications  employed  by  the  laity  for  control  of  hemorrhage  or  for 
the  promotion  of  healing.  The  first  lesson  to  learn  in  this  regard 
is  that  after  bleeding  is  checked  it  is  better  to  leave  the  accu- 
mulated clots  on  the  wound  surface  until  one  is  ready  to  pro- 
ceed with  the  work  along  aseptic  or  antiseptic  lines.  This  rule 
obtains  in  cases,  too,  where  a  sterile  emergency  dressing  is  at 
hand.  The  blood  is  a  far  better  protective  than  any  substitute, 
and  removal  of  the  clot  is  almost  sure  to  result  hi  infection.  The 


Fig.  72. — Correct  method  of  holding  skin  at  upper  lip.     Incorrect  at  lower  lip. 
The  hemostats  necessarily  devitalize  the  tissues  and  favor  infection. 

region  should  be  shaved  and  scrubbed,  and  then  sterilized  accord- 
ing to  one  of  the  plans  already  enumerated  under  skin  steriliza- 
tion. The  best  plan  is  to  use  benzin  instead  of  soap  for  shaving 
and  to  sterilize  with  iodin.  All  foreign  bodies  must  be  removed, 
such  as  cinders,  dirt,  hairs,  etc.  The  wound  itself  is  now  cleansed 
of  all  clotted  blood  and  fragments  of  tissue,  and  an  attempt  made 
to  rid  it  of  possible  bacteria.  This  is  best  done  by  irrigation  with 
saline  solution  or  alcohol,  or  by  swabbing  it  out  with  tincture  of 
iodin,  1  to  3  per  cent.,  or  with  carbolic  acid  followed  with  alco- 


WOUNDS 


366 


hoi.  These  agents  interfere  but  little  with  primary  union,  and 
are  very  satisfactory  unless  their  application  is  made  some  hours 
after  the  injury,  i.  e.,  after  the  bacteria  have  had  time  to  bury 
themselves  in  the  tissues.  All  devitalized  tissue  should  be  re- 
moved by  knife  or  scissors;  it  may  be  accepted  that  all  vascular 
tissues  are  devitalized  if  they  show  no  bleeding  points  on  incision. 
Such  tissues  must  be  removed,  for  they  will  slough  away  and 
serve  as  a  fine  culture-medium  for  infection.  Shreds  and  fragments 
of  living  tissue,  too,  that  cannot  be  secured  in  position,  as  in 


piK  73._ln  dosing  the  skin  tnu-timi  by  sutures  or  vulsella  prevent  the  edges 
from  rolling  inward. 

lacerated  wounds,  ought  to  be  removed.  Finally,  one  must  see 
to  it  that  the  wound  is  as  dry  as  possible,  and  that  all  oozing  of 
blood  ha>  been  stanched  before  the  next  step  is  undertaken. 
Cleansing  punctured  wounds  and  control  of  hemorrhage  can  only 
be  done  by  slitting  them  open. 

Closure  of  the  wound  now  follows  if.  indeed,  it  is  deemed  best 
to  close  it,  or  if  it  i-  possible.  Certain  wounds  are  purposely 
treated  as  ..pen  woun.U.  and  held  open  by  packing,  as,  for  ex- 
ample tho>e  in  which  there  is  a  possibility  of  tetanus  or  other 
•m-ien.bic  infection,  and  those  which  by  their  nature  cannot  be 


366  PRINCIPLES    OF   SURGERY 

closed.  Moreover,  other  wounds  demand  drainage,  especially 
those  that  are  large  and  have  large  areas  of  damaged  tissue,  or 
in  which  bleeding  cannot  be  satisfactorily  controlled.  In  cases 
where  great  swelling  has  already  occurred  it  may  be  impossible 
to  make  a  satisfactory  closure  and  the  suturing  may  be  postponed 
until  the  swelling  subsides. 

The  purpose  of  closure  of  wounds  is  not  simply  to  repair  the 
breach  in  the  tissues,  but  to  follow  a  definite  plan  and  restore  the 
tissues  as  nearly  to  their  normal  relation  and  function  as  pos- 
sible, and  to  accomplish  healing  with  a  minimum  of  scar  tissue. 
Therefore,  in  closing  wounds  it  is  proper,  with  rare  exceptions, 
to  approximate  like  tissue  to  like,  peritoneum  to  peritoneum, 
fascia  to  fascia,  skin  to  skin,  for,  in  whatever  position  the  ap- 
proximation is  done,  they  will  remain  permanently  after  union. 
On  this  account  it  is  preferable,  where  the  wound  extends  through 
several  superimposed  structures,  to  close  it  with  several  layers 
of  sutures,  one  for  each  important  structure  concerned,  for  it  is 
impossible  to  accomplish  the  same  satisfactory  reposition  with 
through-and-through  sutures. 

It  is  necessary  in  closing  wounds  that  the  edges  be  approxi- 
mated snugly,  with  no  dead  space  in  the  depths  of  the  wound. 
It  is  just  as  necessary  that  the  sutures  shall  not  be  drawn  tightly 
enough  to  do  more  than  this,  a  practice  that  is  too  often  seen 
even  in  surgeons  of  fair  experience.  If  the  suture  is  drawn  tightly 
enough  to  obstruct  circulation  in  the  tissues  within  its  grasp  it 
will  delay  union,  and  if  it  cuts  the  circulation  off  necrosis  will  of 
necessity  occur  and  infection  very  probably,  or  the  sutures  may 
cut  through  the  tissues  and  lose  their  value  altogether  in  addition 
to  unnecessary  crippling  of  the  tissues. 

The  closure  of  wounds  is  usually  effected  by  sutures.  This  is 
universally  practised  hi  the  deeper  structures.  Closure  of  the 
skin  may  be  done  by  sutures,  clips,  or  adhesive  dressings.  The 
former  two  are  preferable,  and  if  there  is  much  depth  to  the 
wound  it  is  better  to  employ  sutures  to  close  the  whole  of  it,  or 
all  but  the  skin,  to  avoid  dead  spaces.  Sutures  should  be  placed 
sufficiently  far  from  the  edge  to  serve  their  purpose,  a  rule  that 
varies  both  with  the  amount  of  tension  imposed  and  the  toughness 
of  the  tissues ;  it  is  necessary  to  place  sutures  in  the  ends  of  severed 
muscles  much  further  back  than  in  fascia  or  skin.  If  it  is  desired 
to  have  as  small  a  scar  as  possible,  the  sutures  should  be  fine  and 
placed  as  close  to  the  edge  as  possible  and  removed  early.  Early 
removal  lessens,  too,  the  chance  of  stitch-hole  abscess,  a  very 
important  fact  in  connection  with  two-time  operations. 

Those  wounds  which  cannot  be  closed  without  dangerous 
tension  on  the  sutures  should  have  the  tension  relieved  by  relaxa- 


WOUNDS  367 

tion  sutures  or  by  adhesive  strips,  which  are  caused  to  extend  a 
satisfactory  distance  away  from  the  cut  edges.  If  these  methods 
produce  too  much  tension  on  the  adjacent  structures  and  threaten 
necrosis  they  should  be  abandoned,  and  the  parts  must  be  dis- 
sected free  sufficiently  far  to  allow  easy  approximation.  If  this  is 
not  feasible  the  wound  must  be  left  to  heal  by  second  intention, 
or  covered  by  grafts  at  the  time  or  subsequently.  The  most  im- 
portant factors  in  suturing  are  closure,  avoidance  of  tension,  of 
constriction,  and  of  fat  or  other  materials  between  the  sutured 
edges. 

The  materials  employed  for  suturing  the  soft  parts  are,  ac- 
cording to  the  practice  of  the  majority  of  surgeons,  very  well 
established,  although  there  are  many  exceptions.  Removable 


Fig.  74. — Wound  sutured  and  ready  for  dressing. 

sutures  may  be  made  of  any  material  that  has  sufficient  strength, 
provided  it  can  be  sterilized;  they  may  be  absorbable  or  non-ab- 
sorbaMe,  with  a  great  preference  for  the  latter,  inasmuch  as 
absorbable  suture  material  in  the  skin  is  more  favorable  to  in- 
fection. Silver-wire,  silk,  or  silkworm-gut,  and  Pagenstecher's 
celloidini/ed  linen  are  commonly  employed.  The  wire  and  silk- 
worm-nut sutures  have  the  advantage  of  having  little  capillarity, 
bein»;  impervious  and  less  favorable  to  infection,  but  they  are  more 
difficult  to  handle,  and  likely  to  irritate  the  surface  unless  their 
free  end>  are  protected.  Silk  is  more  permeable  to  fluids  and  bac- 


368  PRINCIPLES   OF   SURGERY 

teria  than  linen.  In  buried  sutures  catgut  and  kangaroo-tendon 
are  preferred  by  the  majority  of  surgeons,  for  reasons  previously 
given.  However,  hi  the  peritoneal  cavity  non-absorbable  suture 
material  may  be  used  with  just  as  little  risk  as  absorbable,  pro- 
vided it  is  not  an  infected  case;  but  in  cases  of  peritonitis  it  is 
better  to  use  catgut,  for,  while  it  is  more  likely  to  become  infected, 
it  cannot  serve  as  a  permanent  nidus  for  bacteria  and  thus  main- 
tain a  sinus  indefinitely.  After  a  clean  wound  is  closed  it  should  be 
covered  with  a  sterile  dressing,  which  is  left  in  place  from  five  to 
eight  days,  when  the  sutures  will  be  removed,  unless  local  symp- 
toms, soiling,  or  constitutional  symptoms  demand  inspection  of 
the  wound. 

Treatment  of  infection,  inflammation,  and  suppuration  in 
wounds  is  not  different  from  the  rules  already  laid  down,  except 
that  when  suppuration  is  imminent  a  sufficient  number  of  sutures 
are  to  be  removed  to  allow  free  escape  of  fluids. 

In  all  large  wounds,  especially  contused  or  lacerated,  if  infec- 
tion is  certain,  it  is  better  to  close  with  drainage  from  the  begin- 
ning or  to  treat  for  a  time  as  an  open  wound.  The  repeated  or 
continuous  employment  of  antiseptics  in  the  treatment  of  even 
infected  wounds  is  demonstrably  harmful  and  should  not  be  em- 
ployed. The  treatment  hi  such  cases  should  be  along  the  lines 
indicated  hi  the  treatment  of  inflammation. 

Treatment  of  Gunshot  Wounds. — In  gunshot  wounds  which 
resemble  incised,  lacerated,  and  contused  wounds  and  such  like 
the  treatment  is  the  same  as  in  wounds  produced  by  ordinary 
causes.  It  is  in  all  cases,  of  course,  theoretically  preferable  to 
remove  the  bullet,  and  this  is  often  insisted  upon  by  the  patient. 
Practically,  it  is  rare  that  a  bullet  fails  to  be  encysted  and  rare 
that  it  gives  serious  trouble  per  se.  The  facts  of  correct  practice 
may,  therefore,  be  stated  as  follows:  If  a  bullet  lies  close  to  the 
surface,  and  may  be  readily  excised  without  increased  risk  to  life 
or  damage  to  tissues,  it  may  be  removed  according  to  choice; 
if,  by  virtue  of  the  position  of  the  missile,  it  interferes  with  im- 
portant function  the  surgeon  must  decide  whether  removal  is 
more  hazardous  than  to  leave  it,  and  act  in  accordance  with  the 
best  interest  of  his  patient;  if,  by  virtue  of  infection  or  other 
complications  or  sequelae,  necessity  arises  for  excision,  it  may  be 
undertaken  when  such  necessity  arises.  The  plan  of  digging 
about  in  the  tissues  for  a  bullet  that  has  little  chance  to  produce 
harm  should  by  all  means  be  abandoned. 

Ordinarily  the  treatment  of  gunshot  wounds  may  be  sub- 
divided into  immediate  or  prophylactic  treatment  and  subsequent 
surgical  treatment.  It  is  best  that  an  antiseptic  dressing  be  ap- 
plied as  soon  as  possible  after  receipt  of  a  gunshot  wound.  In 


WOUNDS  369 

keeping  with  this  fact,  the  leading  armies  of  the  world  have  an 
emergency  package  supplied  to  each  soldier,  who  is  instructed 
how  to  use  it.  The  sole  object  of  this  package  is  prevention  of 
infection  and  hemorrhage,  and  a  wound  in  which  hemorrhage  is  not 
severe  may  be  securely  protected  until  the  surgeon  can  reach  him. 
Infection  from  fragments  of  clothing  carried  into  the  wound  is 
not  of  sufficient  frequency  to  alter  the  rule.  It  is  better  to  wait 
for  infection  to  develop  in  these  cases. 

In  all  cases  of  gunshot  wounds  attended  with  free  bleeding 
operation  must  be  done  at  the  earliest  moment,  regardless  of 
shock  and  the  location  of  the  bullet,  unless  by  temporary  means 
the  hemorrhage  may  be  controlled.  Most  of  the  soldiers  who  die 
on  the  battlefield  die  of  hemorrhage.  But  no  time  should  be 
wasted  searching  for  bullets. 

In  all  cases  where  the  missile  has  entered  the  peritoneal  cavity 
the  abdomen  should  be  opened  at  the  earliest  possible  moment 
after  control  of  the  bleeding,  perforations  should  be  sought  for, 
and  treated  by  closure  or  excision  as  the  case  may  demand,  and 
subsequent  treatment,  according  to  the  combined  plans  of  Murphy 
and  Fowler. 

If  the  ball  enters  the  pleural  cavity,  and  there  are  no  signs  of 
hemorrhage,  the  indications  are  to  seal  the  wound  of  entrance 
and  of  exit  artificially,  and  await  developments,  meeting  them 
promptly  as  they  arise. 

Gunshot  wounds  of  the  cranial  cavity  are  to  be  dealt  with  ac- 
cording to  the  rules  already  given,  with  the  addition  of  certain 
special  indications.  If  there  is  depression  of  bone,  or  compres- 
sion due  to  subsequent  hemorrhage,  such  pressure  must  be  relieved 
as  soon  as  the  condition  of  the  patient  and  circumstances  will  per- 
mit. The  ball  when  not  easily  accessible,  as  indicated  by  skia- 
graphs made  in  planes  at  right  angles  to  each  other,  should  be 
left  tentatively  in  ttitn,  unless  it  is  causing  dangerous  symptoms. 
The  passage  of  missiles  of  high  velocity  through  the  brain  pro- 
duces instant  death  by  their  explosive  force. 

Poisoned  wounds  are  treated  according  to  the  nature  and 
quantity  of  the  poison.  The  stings  and  bites  of  insects  deposit 
an  acid  poison  into  the  tissues,  and,  unless  the  number  of  such 
wounds  is  great,  cause  no  demand  for  treatment  beyond  immediate 
relief  of  the  local  symptoms:  this  indication  is  best  met  by  the 
application  of  an  alkaline  solution,  which  is  supposed  to  neu- 
trali/e  the  poisonous  acid  to  some  extent.  Snake-bites,  as  well 
as  those  of  other  venomous  reptiles,  demand  immediate  attention, 
as  they  very  frequently  prove  fatal.  First,  the  wound  should 
be  freely  and  deeply  incised  at  the  point  of  entrance  of  each  fang, 
and  abundant  hemorrhage  from  the  capillaries  should  be  en- 
24 


370  PRINCIPLES   OF   SURGERY 

couraged  by  moderately  tight  application  of  a  tourniquet  above 
the  wound,  or  by  suction,  thus  extracting  as  much  of  the  poison 
as  possible  from  the  tissues;  or  the  tourniquet  may  be  applied 
tightly,  so  as  to  shut  off  all  circulation  until  other  measures  may 
be  employed.  It  is  not  the  wound  per  se  that  concerns  us  here, 
but  the  hypodermic  injection  of  an  absorbable  poison.  Patients 
who  are  subjected  habitually  to  the  risk  of  such  wounds  may 
be  immunized  by  the  use  of  antivenomous  serum.  The  treatment 
of  the  general  condition  is  to  be  directed  along  the  line  of  stimula- 
tion, for  which  strychnin  is  the  preferable  drug,  being  used  in 
enormous  doses  with  great  advantage;  whisky  in  large  doses  is  like- 
wise a  favored  remedy;  supportives  and  tonics;  the  body  tempera- 
ture must  be  maintained  by  artificial  heat  and  elimination  must 
be  encouraged,  but  not  to  the  point  of  exhaustion. 


CHAPTER   XXIII 
BURNS 

A  BURN  is  the  pathologic  lesion  resulting  from  the  action 
of  heat  of  such  intensity  as  is  incompatible  with  the  integrity  of 
the  tissues. 

Etiology. — The  causes  of  burns  are  very  variable.  They  are  the 
actual  flame,  contact  of  the  tissues  with  or  their  close  proximity 
to  heated  objects  of  whatever  nature,  exposure  to  radiated  heat, 
as  is  illustrated  by  exposure  to  the  sun's  rays,  exposure  to  steam, 
hot  air,  or  other  gases,  the  appli cation  of  hot  liquids  (scalds), 
electricity,  and  arrays  and  radium.  The  term  "burn"  is  also  ap- 
plied to  the  lesions  resulting  from  the  action  of  acids  and  other 
chemical  (potential)  cauterante. 

Degree  of  Burns. — Ordinarily  three  degrees  of  burns  are  men- 
tioned, although  there  is  a  recent  tendency  toward  the  acceptance 
of  a  fourth  degree. 

Burns  of  the  First  Degree. — Burns  of  the  first  degree  are  those  in 
which  the  action  of  the  heat  has  been  only  sufficient  to  cause 
redness  of  the  skin  due  to  active  hyperemia,  followed  by  paresis 
:iiul  wide  dilatation  of  the  affected  blood-vessels  and  a  passive 
filling  of  the  vessels.  The  most  common  example  of  this  type 
of  burn  is  sunburn.  It  is  also  seen  sometimes  resulting  from  the 
action  of  heat  applied  for  therapeutic  purposes.  The  character* 
istic  features  of  burns  of  the  first  degree  are  erythema,  pain, 
which  is  invariably  of  a  burning  character,  and  slight  swelling  of 
the  affected  area.  The  pain  is  invariably  exaggerated  by  ex- 
posure to  heat  or  to  the  sun's  rays.  These  symptoms  are  at  their 
height  in  from  four  to  twelve  hours  after  receipt  of  the  burn,  and 
from  that  time  gradually  subside  and  are  well  in  two  to  four  days. 
Tin-  younir.  ami  those  who  are  not  habitually  exposed  to  heat  or 
sunlight,  are  much  more  susceptible  to  such  -burns,  especially 
sunburn.  After  the  skin  has  been  exposed  sufficiently  long  to  the 
>un's  rays  it  becomes  "tanned,"  and  after  this  is  much  less  sus- 
ceptible to  sunburn.  After  subsidence  of  the  inflammatory  proc- 
»•-<  the  redness  ^radually  disappears,  the  skin  becomes  browner 
than  it  was  ("tanned")  if  the  burn  is  a  sunburn,  but  not  otherwise, 
ami  the  »levitali/.e<l  layers  of  epidermis  desquamate  in  large,  thin, 
veil-like  pieces. 

Burns  of  the  Second  Degree. — These   are  the  burns  in  which 

371 


372  PRINCIPLES   OF   SURGERY 

the  formation  of  blebs  occurs,  and  the  three  outer  layers  of  the 
epithelial  covering  are  lifted  away  from  the  rete  mucosum  by  the 
accumulation  of  serum  between  them;  this  accumulation  is  al- 
most instantaneous.  The  most  frequent  burn  of  the  second 
degree  is  the  result  of  scalds,  steam,  or  hot  gases,  and  by  the  com- 
bustion of  inflammable  fluids  (gasoline)  in  contact  with  the  skin. 
The  second  degree  burns  are  often  attended  by  more  or  less  ex- 
tensive first  degree  burns.  The  fluid  distending  the  vesicles  is 
straw  colored  and  often  coagulated.  This  seems  to  be  especially 
the  case  where  the  heat  has  been  held  for  some  time  in  contact 
with  the  surface,  as  in  cases  where  molten  iron  has  been  spilled 
in  the  shoe.  The  presence  of  the  blebs,  which  may  be  ruptured  or 
intact,  dependent  upon  the  thickness  of  the  skin,  and  pain  are  the 


Fig.  75. — Scald  of  second  degree  of  left  upper  extremity. 

characteristic  local  symptoms.  If  the  blebs  have  been  ruptured 
in  burns  of  the  thick  skin  of  the  palm  and  the  sole,  the  burned 
skin  is  drawn  into  a  creased  or,  fluted  wrinkled  shape.  The  pain 
is  severe,  and  is  intensified  by  exposure  to  ordinarily  harmless 
degrees  of  heat,  or  by  removal  of  the  cuticle  and  exposure  to  the 
atmosphere  and  by  infection.  It  remains  intense  for  a  few  days 
and  gradually  subsides  as  healing  occurs;  it  is  protracted  indef- 
initely by  infection.  Healing  of  burns  of  the  second  degree  should 
be  attended  by  no  scar-formation  unless  infection  occurs. 

Burns  of  the  Third  Degree. — In  this,  according  to  the  older 
standards,  intensest  form  of  burns  the  burn  may  extend  slightly 
or  vastly  deeper  than  in  burns  of  the  second  degree.  When  the 
cutis  is  burned,  with  or  without  destruction  of  the  underlying 
structures,  it  is  known  as  a  burn  of  the  third  degree.  It  includes 


BURNS 


373 


all  burns  in  which  an  eschar  is  produced  and  cooked  or  charred 
tissues  found.  It  is  the  type  of  bum  that  invariably  results  in 
the  formation  of  an  ulcer,  when  the  eschar  is  separated  from  its 
attachments  by  the  process  of  granulation.  Burns  of  the  first 
and  second  degree  may  be  associated  with  it.  Furthermore,  it  is 
the  type  of  burn  that  invariably  and  necessarily  results  in  scar- 
formation,  regardless  of  the  presence  or  absence  of  infection,  and 
i<  productive  of  all  the  hideous  cicatrices  and  deformities  that 
affect  those  who  have  had  severe  burns.  These  scars  may  develop 
into  keloids,  or  later  develop  a  Marjolin's  ulcer,  or  produce  epi- 
theliomata.  Of  1720  cancers  studied  by  von  Neve,  in  India,  848 


were  cancers  of  the -upper  thigh  and  abdomen  consequent  upon 

scars  produces!  by  the  custom  of  the  natives  of  currying  fire- 
ba>ket>  under  their  clothing.  The  occurrence  of  burns  and  scalds 
in  the  mouth  and  throat  may  cause  most  urgent  symptoms  by 
becoming  complicated  with  edema,  of  the  glottis,  which  may  re- 
quire tracheotomy  or  intubation  to  prevent  asphyxiation.  The 
local  symptoms  of  burns  of  the  fourth  degree  are  per  se  le»  intense 
than  those  of  the  second,  owing  to  the  fact  that  fourth  degree 
burns  de-troy  the  rutanenu-  nerve-endinu-:  but.  inasmuch  as  the 
other  two  degrees  are  always  present,  the  presence  of  pain  is  to 
be  noted  as  the  ini)M>rt:int  >ymptom. 


374  PRINCIPLES   OF   SURGERY 

Burns  of  the  Fourth  Degree. — This  is  sometimes  used  to  signify 
those  burns  in  which  the  burned  tissues  are  completely  charred; 
or  when  a  part  is  exposed  to  prolonged  intense  heat  the  tissues 
are  carbonized,  and  the  process  is  called  carbonization. 

Pathology. — The  local  pathologic  changes  of  burns  of  the  first 
and  of  the  second  degree  are  apparent  from  the  preceding  dis- 
cussion. Those  of  the  second  degree  are  capable  of  resulting  in 
cicatrices  only  when  suppuration  occurs  and  destroys  the  papillae 
of  the  skin,  being,  therefore,  amenable  to  control  by  correct  treat- 
ment. In  burns  of  the  third  degree  the  tissues  are  cooked  or  car- 
bonized. The  vessels  of  the  skin,  if  it  is  not  too  completely  de- 
stroyed, appear  on  the  burnt  surfaces,  hi  the  form  of  dark-brown 
arborescent  figures,  an  important  fact  in  forensic  medicine,  for 
these  figures  do  not  show  when  the  body  was  dead  prior  to  the 
burning.  It  is  superfluous  to  add  that  if  the  large  vessels  are 
affected  thrombosis  occurs. 

The  general  pathologic  changes  are  insignificant,  and  do  not 
suggest  an  adequate  explanation  for  death.  Ecchymosis  of  the 
mucous  and  serous  surfaces  and  in  the  muscles  is  found;  edema 
of  the  brain  and  the  meninges;  occasionally  duodenal  ulcer  of 
thrombotic  and  infective  origin ;  and  certain  changes  of  the  viscera 
indicative  of  intense  intoxication,  even  when  death  has  occurred 
so  early  as  to  eliminate  the  possibility  of  an  explanation  on  the 
hypothesis  of  infection ;  they  are  degeneration  of  the  heart  muscle, 
kidneys,  and  liver,  with  endothelial  swelling  and  proliferation  in 
the  lymph-nodes,  similar  to  the  changes  found  in  acute  infections 
(Adami). 

Constitutional  Symptoms. — The  manifestation  of  constitu- 
tional symptoms  depends  both  on  the  degree  and  the  extent  of 
the  burn,  but  more  especially  upon  the  latter,  and  upon  the 
presence  or  absence  of  infection.  Small  burns  of  any  degree  pro- 
duce no  important  general  symptoms,  although  even  after  these 
the  temperature  may  fall.  In  large  burns,  even  of  the  first  degree, 
the  symptoms  are  often  intense. 

Immediately  following  a  severe  or  extensive  burn  the  tempera- 
ture is  subnormal,  but  may  rise  considerably  above  normal  shortly 
before  death.  Rectal  temperature  in  cases  of  severe  burns  often 
registers  several  (3  to  4)  degrees  higher  than  the  axillary.  Col- 
lapse or  shock,  in  varying  intensity,  is  usually  a  dominant  char- 
acteristic hi  severe  burns;  it  is  not  uniform.  The  temperature  is 
subnormal,  the  skin  is  pale  and  cold,  the  pulse  rapid,  and  the 
mind  apathetic.  The  patient  may  vomit,  and  often  complains 
of  thirst.  If  vomiting  occurs  shortly  after  a  severe  burn,  it  sig- 
nifies an  unfavorable  prognosis.  The  urine  is  scanty  and  may 
contain  hemoglobin;  even  in  mild  burns  the  urine  is  found  to  con- 


BURNS  375 

tain  albumoses  as  the  case  progresses.  In  fatal  bums  the  condi- 
tion grows  gradually  or  rapidly  worse,  the  apathetic  condition  is 
replaced  by  delirium  and  convulsions  (clonic),  the  skin  is  cya- 
nosed,  diarrhea  and  vomiting  occur,  and  coma  and  collapse  follow. 

Occasionally  shock  does  not  appear  as  a  symptom  even  of 
fatal  burns,  but  the  temperature  rises  above  normal,  the  patient  is 
restless,  excited,  and  complains  of  the  pain  he  suffers.  This  Is  fol- 
lowed by  exhaustion  and  coma  a  short  while  before  death. 

Prognosis. — Of  whatever  degree  it  may  be,  a  burn  covering 
two-thirds  of  the  body  surface  almost  certainly  results  in  death; 
a  burn  of  half  the  skin  surface  probably  causes  death;  and  a  burn 
of  one-third  of  the  body  surfaces  very  frequently  kills.  It  is  an 
established  fact  that  immediately,  and  for  some  time  continuously, 
after  a  burn  there  appear  in  the  blood  undetermined  toxic  agents 
which  play  an  important  r61e  in  the  production  of  the  general 
pathologic  changes  and  death.  Another  frequent  cause  of  death 
is  shock.  A  third  factor  to  which  the  cause  of  death  is  attributable 
is  the  loss  of  plasma  from  the  blood  in  burns  of  the  second  degree. 
Burns  are  unquestionably  more  serious  in  the  young,  the  old,  the 
feeble,  and  delicate,  and  hi  alcoholics,  the  latter  being  more  sus- 
ceptible to  lesions  of  the  viscera.  Death  may  result  from  a  com- 
plicating duodenal  ulcer.  Burns  of  the  chest  and  abdomen  are 
more  serious  than  those  of  the  remaining  parts  of  the  body. 
Naturally,  burns  of  the  pharynx  and  larynx  are  exceedingly  grave. 

In  those  burns  not  of  themselves  necessarily  fatal  the  most 
frequent  cause  of  death  unquestionably  is  infection.  Naturally 
it  does  not  concern  us  hi  burns  of  the  first  degree,  but  hi  all  others 
it  is  of  the  greatest  interest. 

It  is  safe  to  say  that  all  second  degree  burns  heal  without  scar- 
formation,  unless  infection  has  occurred  and  destroyed  the  sur- 
face of  the  skin  proper.  The  redness  resulting  from  such  burns 
disappears  hi  a  few  months.  It  is  likewise  important  to  inform 
the  patient  who  has  a  third  degree  burn  that  healing  will  neces- 
sarily result  in  cicatrization  and  possibly  an  exceedingly  ugly 
deformity. 

Treatment. — The  treatment  of  burns  may  be  subdivided  into 
the  treatment  of  the  general  condition  and  the  treatment  of  the 
burn  itself.  The  former,  naturally,  is  necessary  only  when  the 
lesion  is  of  sufficient  intensity  to  produce  a  marked  constitutional 
impression  or  when  anodynes  are  necessary  for  relief  of  pain. 
Shock  is  to  be  combated  here,  according  to  the  rules  already 
laid  down,  and  in  those  cases  which  suffer  the  loss  of  large*  quan- 
tities of  fluids  from  the  blood  it  is  essential  to  maintain  the 
proper  consistency  of  the  blood  by  continued  administration  of 
fluids  by  mouth,  by  rectum,  snhcutaneously,  or  intravenously. 


376  PRINCIPLES   OF   SURGERY 

The  local  treatment  of  burns  may  be  summed  up  in  the  brief 
statement:  prevent  infection  and  control  pain.  It  may  be  added 
that  the  accomplishment  of  the  former  is  the  most  rapid  and  sure 
plan  of  alleviating  and  preventing  the  latter.  The  plans  hereto- 
fore in  vogue  of  applying  various  lotions  and  ointments,  many  of 
which  are  not  sterile,  have  only  added  insult  to  injury.  Those 
which  contain  toxic  drugs,  as  carbolic  acid,  mercury,  and  iodin,  or 
drugs  which  may  liberate  iodin  are  positively  contra-indicated  in 
large  burns,  and  those  which  are  not  toxic,  such  as  carron  oil 
and  picric  acid,  while  they  represent  an  improvement  over  the 
first-named  group,  demonstrably  do  not  give  *he  best  results. 

Burns  of  the  first  degree  are  to  be  treated  by  making  such 
applications  as  will  exclude  the  air.  Simple  dry  dressings,  with 
or  without  the  use  of  dusting-powders,  moist  dressings  of  saline 
solution,  boric  acid,  or,  if  the  burns  are  not  large,  the  application 
of  a  1  per  cent,  solution  of  carbolic  acid  (see  Gangrene).  The  ad- 
vantage gained  by  the  employment  of  carbolic  acid  is  its  anodyne 
effect  upon  the  nerve  endings.  Ointments  or  oily  solutions  may 
likewise  be  employed  hi  these  burns.  Vaselin,  boric  acid,  or  zinc 
oxid  ointment  are  probably  as  good  as  any.  The  important  fact 
to  be  remembered  hi  these  cases  is  protection  from  the  atmo- 
sphere, and  any  plan  that  accomplishes  this  end  satisfactorily 
is  good.  The  body  of  the  patient  may,  in  extensive  burns  of  the 
first  degree,  be  placed  in  a  warm  bath  of  saline  solution  or  a  weak 
solution  of  sodium  bicarbonate;  this  relieves  the  pain,  and  may  be 
kept  up  continuously  for  any  necessary  length  of  tune. 

Sunburn  may  be  prevented  by  the  application  of  vaselin  or 
ointments  before  exposure. 

Burns  of  the  second  degree  and  of  the  third  degree  are  open 
wounds,  which  universally  become  infected  soon  after  their 
occurrence,  and  must  consequently  be  dealt  with  accordingly. 
The  most  important  feature  of  the  local  treatment  of  these  burns 
is  the  prevention  of  infection.  This  can  be  done  only  by  a  rigid, 
tedious,  and  often  protracted  process  of  preparation  of  the  surface. 
Of  course,  if  the  burn  is  small  it  may  be  sterilized  by  the  applica- 
tion of  tincture  of  iodin,  2  to  7  per  cent.;  if  it  is  large,  one  dares 
not  employ  it.  If  the  patient  is  a  child,  or  if  the  burn  is  extensive 
and  not  necessarily  fatal,  a  general  anesthetic  should  be  admin- 
istered, and  the  whole  burned  area  be  scrubbed  with  sterile  water, 
sterile  soap,  and  a  sterile  soft  brush  or  sponge  until  it  is  clean.  All 
foreign  particles  and  shreds  of  tissue  that  are  loose  should  be 
removed;  the  surface  should  then  be  washed  with  ether  or  alco- 
hol and  rinsed  with  saline;  blebs  should  be  punctured  near  the 
edge  and  their  contents  allowed  to  escape,  but  the  cuticle  should  not 
be  removed.  When  the  surface  has  now  been  entirely  dried,  the 


BURNS  377 

dressings  are  applied  dry  and  allowed  to  remain  in  situ  for  a  week 
or  more,  unless  the  general  or  local  condition  demands  their 
removal.  To  prevent  sticking  of  the  dressing  to  the  wound  surface 
stt'rili/<i<l  vaselin,  or,  as  I  believe  to  be  more  valuable,  a  sterile 
paste  of  bismuth,  20  to  30  per  cent,  in  vaselin,  may  be  applied. 
Burns  of  the  second  degree  are  healed  when  the  dressing  is  re- 
moved in  seven  to  ten  days  and  the  eschar  of  third-degree  burns 
is  ready  to  come  away.  If  infection  occurs,  the  plan  of  treatment 
is  the  same  as  that  indicated  in  the  chapters  on  Inflammation  and 
Ulceration.  The  large  granulation  surfaces  of  third  degree  burns 
must  be  skin-grafted  pro  re  nata. 

The  best  plan  of  treatment  for  electric  burns,  which  under  the 
usual  plans  heal  exceedingly  slowly,  is  to  dissect  the  burned  tissue 
away  and  suture  with  the  hope  of  primary  union. 

The  treatment  of  x-ray  and  radium  burns  is  the  same  as  that 
of  ordinary  burns  of  the  same  degree. 


CHAPTER    XXIV 
FROST-BITE,   FREEZING,   AND   CHILBLAINS 

THESE  lesions  all  result  from  exposure  to  low  degrees  of  cold 
sufficiently  long  to  kill  or  cripple  the  tissues.  The  degree  of  cold 
and  the  time  of  exposure  required  to  produce  frost-bite  or  freezing 
varies  very  much  with  the  condition  of  the  individual  and  with 
the  habits  of  the  people;  those  who  live  in  mild  southern  climates 
are  much  more  easily  affected  than  those  who  have  been  reared 
hi  cold  climates;  the  weak,  anemic  and  thin,  the  very  young  and 
the  old  are,  as  a  rule,  more  susceptible  than  the  robust  and  vigor- 
ous. However,  people  who  show  the  same  apparent  vigor  vary 
very  much  in  their  resistance  to  cold,  due  to  idiosyncrasies  which 
are  not  understood.  Manifestly,  cold  affects  the  body  much  more 
rapidly  if  at  rest  than  when  muscular  activity  is  continued.  It 
is,  therefore,  important  that  individuals  who  are  exposed  to  cold 
shall  continue  to  move,  and  not  yield  to  the  temptation  to  lie  down 
and  sleep,  a  tendency  sure  to  appear  when  the  body  begins- to  be 
very  cold.  Cold  is  more  apt  to  affect  the  exposed  parts  of  the 
body,  naturally,  and  those  portions  in  which  the  activity  of  the 
circulation  is  interfered  with  by  pressure.  The  hands,  the  feet, 
the  nose,  and  ears  are  most  frequently  affected. 

Pathology. — The  first  effect  of  cold  is  to  produce  contraction 
of  the  arterioles,  producing  temporary  anemia.  This  is  followed 
by  passive  dilatation  and  transudation  of  serum,  which  causes 
blebs  to  form.  As  the  cold  is  prolonged,  the  tissues  and  the 
blood  freeze  and  the  blood-corpuscles  are  destroyed,  liberating 
their  hemoglobin. 

Frost-bites  are  described  in  three  degrees,  corresponding  very 
well  in  the  extent  of  injury  with  the  three  degrees  of  burns. 

First  Degree. — This  is  the  mildest  form  of  frost-bite,  and,  when 
the  tissues  are  thawed,  results  in  redness  (often  bluish)  and  swell- 
ing, due  to  paresis  of  the  smaller  blood-vessels.  The  discoloration 
and  swelling  may  persist  for  a  week  or  more  and  gradually  disap- 
pear, although  a  permanent  dilation  may  result  and  remain  in- 
definitely. 

When  the  exposure  to  cold  is  prolonged  or  frequently  repeated, 
especially  in  anemic  and  chlorotic  individuals,  a  persistent  or 
recurrent  and  uncomfortable  lesion,  known  as  chilblain  or  pernio, 

378 


FROST-BITE,    FREEZING,    AND    CHILBLAINS  379 

occurs.  Chilblains,  or  pemiones,  appear  most  frequently  on 
those  parts  usually  affected  by  frost-bite,  namely,  the  hands,  feet, 
nose  and  ears,  and  rarely  the  penis.  They  are  most  common  on  the 
heel  and  external  margin  of  the  foot.  They  are  purplish  or  reddish- 
purple  patches,  elevated  somewhat  above  the  surrounding  normal 
skin  and  presenting  a  glossy  surface.  Vesication  and  ulceration 
may  appear  on  the  surface  of  the  chilblain. 

The  patient  complains  of,  and  may  be  sorely  tormented  by, 
the  itching  or  burning  sensation  present,  which  is  frequently 
intensified  by  increasing  the  temperature  of  the  surface,  and  is 
only  rendered  worse  by  scratching  or  rubbing.  During  the  warmer 
seasons  chilblains  disappear,  but  return  with  each  winter,  and  majr 
continue  indefinitely. 

Second  Degree. — In  frost-bites  of  the  second  degree  the  tis- 
sues have  suffered  still  more  intensely.  When  thawing  occurs 
the  skin  becomes  dark  or  red  or  purple  in  hue,  and  swelling  occurs. 
The  more  rapidly  the  part  is  thawed,  the  more  intense  the  color 
and  the  greater  the  swelling,  provided  the  tissues  are  lax.  Blebs, 
which  may  be  very  large,  form,  and  are  filled  either  with  a  turbid 
or  a  clear  fluid.  Associated  with  these,  as  in  the  case  of  burns, 
are  frost-bites  of  the  first  degree.  Healing  occurs  under  a  scab, 
after  rupture  of  the  blebs,  without  cicatrization.  Perniones  may 
re-ult  from  frost-bites  of  the  second  degree;  at  any  rate,  tissues  so 
affected  are  less  resistant  afterward,  especially  to  cold.  Ulcera- 
tion may  result  from  these  frost-bites  and  heal  necessarily  with 
scar  formation. 

Third  Degree. — In  this  degree  the  surface  may  be  covered 
with  blebs  or  mottled  blue  and  white  and  mortification  occurs  hi 
varying  depths.  When  thawing  occurs  there  is  no  reaction,  no 
swelling,  no  redness;  only  the  bluish  color,  and  possibly  the  forma- 
tions of  blebs;  when  the  latter  dry  they  leave  the  surface  covered 
with  brown  crusts.  The  nails,  the  fragments  of  skin,  the  scabs, 
ami  the  dead  tissues  later  come  away,  and  leave  ulcers  which  may 
he  hy  |><  (sensitive  or  hypersensitive  and  run  an  unhealthy  course. 
If  the  deep  structures  are  frozen  gangrene  results  and  a  line  of 
demarcation  forms.  The  surface  surrounding  the  dead  tissues 
frequently  becomes  a  bright  red  color. 

Fourth  Degree. — Fourth  degree  frost-bites  are  sometimes  de- 
scribed, and  embrace  those  cases  hi  which  an  entire  extremity  is 
frozen. 

Symptoms. — The  local  symptoms  experienced  on  exposure 
to  coltl  are  burning,  smarting,  or  tingling  of  the  parts,  and  this 
may  be  followed  by  pain  more  or  le»  severe.  As  the  freezing  ad- 
vances the  pain  may  >ul»ide  and  the  tingling  and  burning  cease, 
owing  to  the  anesthetic  action  of  cold  on  the  cutaneous  nerve 


380  PRINCIPLES   OF   SURGERY 

supply,  and  further  progress  of  the  case  may  produce  but  in- 
significant discomfort. 

In  general  freezing,  as  the  body  grows  colder  intense  rigors  ap- 
pear and  continue.  There  is  an  irresistible  tendency  to  sleep  as 
the  lassitude  increases,  and,  unless  the  individual  can  continue 
to  move  and  overcome  his  inclination  to  lie  down  and  sleep,  death 
is  sure  to  follow.  The  temperature  of  the  body  is  gradually  re- 
duced until  it  reaches  very  low  points.  Following  restoration  of 
the  body  to  a  warmer  atmosphere  the  temperature  gradually  rises, 
often  to  several  degrees  above  normal  (104°  F.). 

Prognosis. — The  outcome  of  cases  of  freezing  of  the  first  and 
the  second  degree  is  very  favorable.  Chilblains  may  result  from 
either  and  ulcers  from  the  second  degree  frost-bites.  In  frost- 
bites of  the  third  degree  there  is  more  or  less  destruction  of  tissue, 
but  the  extent  of  damage  cannot  be  estimated  until  a  line  of  de- 
marcation develops.  In  general  freezing  recovery  has  been 
recorded  after  the  rectal  temperature  had  reached  as  low  a  mark 
as  75.2°  F.,  but  the  majority  of  such  doubtless  die,  and  many  die 
whose  rectal  temperature  has  not  been  reduced  to  90°  F.  The 
reaction  of  the  patient  and  the  rise  of  his  temperature  to  normal 
are  not  positive  proof  of  ultimate  recovery.  Death  may  occur 
several  days  after  such  an  occurrence.  In  general  freezing  the 
prognosis  is  very  bad,  and,  if  life  is  saved,  there  is  sure  to  be 
severe  loss  of  parts. 

Treatment. — When  frost-bitten  patients  are  discovered,  it 
matters  not  of  what  degree,  the  most  important  thing  to  know  is 
that  the  part  must  be  restored  to  normal  temperature  by  slow 
processes;  the  more  intense  the  freezing  and  the  more  general,  the 
slower  the  restoration,  even  if  it  requires  several  hours;  and  that 
introducing  the  patient  into  a  warm  room  or  the  application  of 
warm  substances  is  certain  to  prove  harmful.  The  frozen  parts 
should  be  rubbed  with  snow  or  shaved  ice,  and,  as  reaction  begins 
to  be  established,  the  temperature  of  the  room  can  be  raised  very 
slowly  to  a  comfortable  point,  and  the  snow  or  ice  replaced  with 
cold  water.  As  the  circulation  is  reestablished  the  pain,  tingling, 
and  burning  may  reappear,  or,  even  in  frost-bites  of  the  first  de- 
gree, the  skin  may  remain  insensitive  for  several  days. 

The  parts  that  have  been  frozen  should  be  protected  from 
heat  and  irritation,  and  often  require  the  application  of  cold,  hi 
the  form  of  lotions  or  otherwise. 

If  discoloration  and  swelling  tend  to  become  chronic,  massage, 
artificial  active  hyperemia,  and  bandaging  should  be  employed. 

In  frost-bites  of  the  second  and  the  third  degree  every  pre- 
caution should  be  taken  to  prevent  infection,  according  to  the 
rules  laid  down  in  the  treatment  of  burns.  Surfaces  whose  epi- 


FROST-BITE,    FREEZING,    AND    CHILBLAINS  381 

thelium  has  been  destroyed  should  be  covered  with  sterile  bland 
ointments,  to  prevent  adherence  of  the  dressing. 

When  a  line  of  demarcation  forms,  removal  of  the  gangrenous 
tissue  must  be  done  according  to  the  demands  of  the  case. 

Chilblains  are  to  be  treated  by  stimulating  applications,  as 
iodin  in  one  of  its  forms,  active  hyperemia,  protection  from  irrita- 
tion, pressure  and  extremes  of  temperature;  but,  very  especially,  by 
correction  of  the  general  condition  which  predisposed  to  them. 


CHAPTER    XXV 
FRACTURES 

A  FRACTURE  is  the  solution  of  continuity  of  bone  or  cartilage 
by  sudden  violence.  A  fracture  is  a  break  of  either  bone  or  car- 
tilage. 

Cause. — The  etiology  of  fracture  is  subdivided  into  predis- 
posing, or  pathologic,  and  exciting,  or  mechanical,  causes. 

The  factors  which  favor  the  production  of  fractures  are  those 
which  of  themselves  reduce  the  resistance  of  the  bone  to  strains. 
Hence,  any  pathologic  condition  which,  like  rickets,  tends  to 
prevent  the  deposit  of  a  sufficient  quantity  of  calcareous  material 
hi  the  bones  leaves  them  weaker  than  normal;  any  condition 
which,  like  malignant  tumors,  primary  or  secondary,  reduces 
the  strength  of  the  bone  by  absorption  or  permeates  it  with  fleshy 
material  or  thins  out  its  walls  until  they  are  mere  shells  by  grow- 
ing in  the  medullary  canal  favors  fracture;  any  disease  or  condi- 
tion which  diminishes  the  connective-tissue  content,  as  osteo- 
myelitis, or  relatively  increases  the  earthy  material,  thereby  in- 
creases the  fragility  of  the  bone  and  favors  fracture.  A  patho- 
logic fracture  is  one  which  has  been  made  possible  by  pathologic 
processes  affecting  the  bone,  and  occurs  under  circumstances  of 
normal  function.  It  is  manifest,  too,  that  such  processes,  when  not 
sufficient  to  cause  fracture  within  the  limits  of  ordinary  bodily 
exercise,  render  the  bones  more  susceptible  to  traumatisms. 
Atrophy  from  disuse  always  weakens  the  bones. 

The  exciting  or  mechanical  cause  of  fracture  is  a  force  applied 
to  the  structure  concerned.  The  cause  may  be  direct  or  indirect; 
it  may  be  due  to  the  muscular  effort  of  the  individual,  to  a  purely 
extraneous  force,  or  to  the  two  combined.  A  direct  fracture  is  one 
produced  at  the  point  of  application  of  the  causative  force.  An 
indirect  fracture  is  one  produced  at  some  other  point  than  the 
point  of  its  application.  It  may  be  assumed,  for  practical  pur- 
poses, that  in  direct  fractures  the  external  force  is  the  sole  cause 
of  fracture.  In  indirect  fractures  the  external  force  may  or  may 
not  be  the  sole  cause;  it  is  frequently  supplemented  by  muscular 
contraction  of  the  part.  Occasionally,  in  both  health  and  disease — 
e.  g.,  tetanus — fractures  occur  in  healthy  bones  as  the  result  of 
muscular  contraction  alone.  The  site  of  fracture  from  indirect 
causes  is  determined  by  the  point  of  least  resistance  in  the  bone, 
and  by  the  level  at  which  the  greatest  strain  is  produced  by  the 

382 


FRACTURES  383 

forces  which  serve  to  produce  the  fracture.  It  does  not  occur  at 
either  of  these  points,  but  between  them. 

When  a  fracture  is  produced  there  occurs  not  only  severance 
of  the  osseous  tissue  and  the  soft  structures  encased  within  it,  but 
the  periosteum  almost  invariably,  and  the  surrounding  soft  struc- 
tures frequently,  especially  if  they  are  closely  attached  to  it,  are 
more  or  less  extensively  torn:  the  periosteum  is  at  times  stripped 
up  some  distance  from  the  point  of  fracture.  While  the  perios- 
teum surrounding  the  fracture  may  be  completely  severed,  there 
is  usually  a  part  of  its  circumference,  the  side  of  the  smaller  angle, 
that  escapes  rupture,  which  is  known  as  the  periosteal  bridge. 
More  or  less  bleeding  takes  place  from  the  severed  vessels,  and  the 
blood  accumulates  between  and  around  the  severed  ends  of  bone 
and  may  escape  for  some  distance  into  the  surrounding  connect- 
ive tissue. 

Types  of  Fracture. — A  simple  fracture  is  one  in  which  the  injury 
to  the  soft  parts  is  little  or  no  greater  than  the  possibility  of 
fracture  demands,  and  in  which  no  important  structure  other  than 
the  bone  is  injured. 

A  compound  fracture  is  one  hi  which  a  wound  is  produced 
leading  from  a  mucous  or  cutaneous  surface  to  the  fracture.  It 
is  not  compound  so  long  as  there  is  no  such  communication,  al- 
though the  wound  and  the  fracture  may  both  exist  as  the  result 
of  the  same  injury.  The  trauma  producing  the  fracture  may  be  the 
cause  of  the  wound,  as  hi  a  kick  by  a  horse  where  the  shoe  cuts 
down  to  the  bone  and  breaks  it.  The  wound  may  be  the  result 
of  the  fractured  fragments  perforating  the  soft  parts  from  within 
outward;  tliis  is  the  usual  cause  of  fractures  being  compound  when 
produced  by  indirect  force.  The  wound  may  likewise  be  pro- 
duced by  the  close  attachment  of  the  soft  parts  to  the  periosteum; 
this  type  is  common  in  fractures  of  the  body  of  the  lower  jaw, 
where  it  is  rare  for  a  fracture  to  occur  without  rupturing  the 
do-ely  attached  mucoperiosteum.  Gunshot  fractures,  in  the 
very  nature  of  the  case,  are  usually  compound,-  especially  if  pro- 
duced l»y  discharges  from  small  arms. 

A  c<>ni[>h'c<it«l  fracture  is  one  hi  which  some  other  important 
structure  is  injured,  such  as  the  rupture  of  important  muscles, 
tendons,  arteries  or  nerves,  or  the  association  of  a  luxation,  or  the 
puncture  of  a  lung  by  the  fragments  of  a  broken  rib. 

A      milt  fracture  is  the  fracture  of  a  bone  at  one  point. 

A  doubl  fracture  is  a  fracture  of  a  single  bone  at  two  points. 

A  mnlti'iilf  fracture  is  a  fracture  of  a  bone  at  more  than  two 
points.  The  lines  of  fracture  do  not  communicate. 

A  cinnminntul  fracture  is  one  in  which  the  hone  i-  crushed  or 
broken  into  small  fragments.  Here  the  planes  of  fracture  com- 


384  PRINCIPLES   OF   SURGERY 

municate  with  each  other.  In  thin  or  flat  bones  such  a  fracture 
is  sometimes  spoken  of  as  egg-shell  fracture. 

A  unilateral  fracture  is  a  fracture  of  one  side  of  a  median  bone, 
for  example,  the  mandible,  while  a  bilateral  fracture  is  a  break  of  the 
median  bone  on  each  side  of  the  median  line. 

The  terms  transverse,  oblique,  and  longitudinal  are  sufficiently 
clear  to  require  no  definition.  They  refer  to  fractures  of  long 
bones,  as  a  rule.  A  spiral  fracture  is  one  hi  which  the  line  of  frac- 
ture runs  in  a  more  or  less  perfect  spiral  around  the  circumference 
of  the  bone  and  is  produced  by  a  twisting  force.  Longitudinal 
fractures  frequently  are  only  fissures. 

A  serrated  fracture  is  one  in  which  the  fractured  ends  are  irreg- 
ularly jagged. 

A  denticulated  fracture  is  one  in  which  a  long  sliver  remains 
attached  to  one  fragment  while  it  is  split  up  from  the  other.  This 
fracture  and  very  oblique  fractures  are  especially  likely  to  be  com- 
pound if  there  is  great  angular  displacement  at  the  time  of  oc- 
currence. 

A  depressed  fracture  is  one  in  which  the  bone  is  driven  per- 
ceptibly into  the  cavity  the  bone  forms.  This  term  applies  es- 
pecially to  fracture  of  the  ribs  and  of  the  cranial  bones. 

An  impacted  fracture  is  one  in  which  the  fragments  are  driven 
immovably  together  after  fracture  occurs,  as  is  observed  in  those 
cases  where  the  shaft  of  a  long  bone  is  forced  into  the  spongy  head. 
Manifestly  those  signs  dependent  upon  the  mobility  of  the  frag- 
ments relative  to  each  other  are  wanting  here. 

Besides  the  above,  representing  the  complete  fractures,  are  the 
incomplete  fractures,  which  embrace  green-stick  fractures,  fissures, 
and  certain  depressions  of  bone,  as,  for  example,  hi  the  cranium, 
when  the  outer  table  is  driven  down  upon  the  inner.  Incomplete 
fracture  simply  means  that  the  fragments  remain  more  or  less 
firmly  bound  in  their  original  position  and  are  hi  no  case  suffi- 
ciently broken  to  allow  removal  of  a  fragment  without  further 
breaking.  Green-stick  fractures  occur  in  those  whose  bones  have 
not  yet  fully  ossified,  hence  hi  the  young.  The  term  is  aptly  ap- 
plied, for,  as  in  breaking  a  green  stick,  the  fibers  on  the  convex  sur- 
face break,  while  those  on  the  concave  surface  only  bend. 

Fissures  are  fractures  in  which,  although  the  bone  may  be 
separated  partially  or  completely,  there  was  not  sufficient  displace- 
ment to  rupture  the  periosteal  covering  extensively.  Originally 
thought  to  be  rare,  they  are  now  known,  thanks  to  radiography,  to 
be  much  more  common. 

Epiphyseal  separation,  while  not  exactly  embraced  in  the  de- 
finition of  fracture,  practically  belongs  to  the  group.  There  is  no 
break  of  osseous  tissue  here,  but  a  separation  of  the  epiphysis  from 


FRACTURES 


385 


the  diaphysis.  They  are,  of  course,  transverse,  and  have  this  dis- 
advantage over  fractures,  namely,  that  after  healing  the  epiph- 
ysis  becomes  ossified  and  further  growth  of  this  bone  in  length 
from  the  affected  epiphysis  becomes  impossible;  an  important 
fact  to  remember  in  rendering  a  prognosis. 

Signs  and  Symptoms  of  Fracture. — There  are  three  classic 
signs  of  fracture,  the  unmistakable  presence  of  any  one  of  which 
makes  a  positive  diagnosis.  Unfortunately,  we  have  learned  that 
a  large  number  of  fractures  show  neither  of  these  signs,  and  there 


.  77. 


urgicul  neck  of  the  humerus. 


is  a  still  greater  number  in  which,  though  they  might  be  dis- 
covered, their  demonstration  is  positively  harmful.  Going  a  step 
further,  one  may  say  that  so  soon  as  sufficient  evidence  is  at  hand 
to  make  a  diagno>is  all  further  manipulation  should  be  abandoned. 
Those  three  signs  are  crepitus,  preternatural  mobility,  and 
spontaneous  displacement.  By  crepitus  is  meant  the  vibrations, 
heard  or  felt,  produced  by  the  movement  of  the  fragments  on 
each  other.  It  may  be  fine  enough  to  he  called  crepitus  in  its 
proper  meaning  or  coarse  enough  to  feel  and  sound  like  a  distinct 
knock,  and  may  be  distinctly  felt  l»y  the  patient  himself.  In  cases 

25 


386  PRINCIPLES   OF   SURGERY 

where  the  fractured  surfaces  are  not  in  contact,  where  the  fracture 
is  incomplete,  where  the  fragments  are  prevented  from  moving 
by  the  nature  of  the  fracture — e.  g.,  in  impacted  fracture,  or  where 
they  are  held  hi  position  by  surrounding  structures — crepitus  can- 
not be  elicited,  or,  if  so,  only  by  production  of  positive  harm. 
Bones  covered  by  a  large  thickness  of  tissue  reveal  crepitus  less 
plainly  than  more  superficial  ones.  It  must  be  borne  hi  mind 
that  crepitus  is  transmitted  readily  along  the  whole  length  of  a 
fragment,  and  hence  is  often  a  poor  sign  of  itself  to  locate  the 
exact  point  of  fracture,  although  it  is  not  so  readily  transmitted 
across  a  joint  from  one  bone  to  another.  Crepitus  is  elicited  only 
by  manipulation  of  the  part  or  by  attempts  on  the  part  of  the 
patient  to  move  it;  such  motion  or  manipulation  may  in  certain 
fractures  be  of  little  harm,  but  in  others  it  is  baneful  on  account 
of  the  increased  laceration  of  soft  parts  and  increased  hemorrhage 
and  swelling  following  it.  Besides,  it  is  universally  painful,  except 
in  certain  pathologic  fractures. 

Preternatural,  or  Unnatural  Mobility. — This  signifies  that  mo- 
bility is  found  at  some  point  hi  the  course  of  a  bone,  where  no 
motion  would  be  found  if  the  bone  were  intact.  It  is  a  most  im- 
portant sign  when  discoverable  without  undue  traumatism.  It 
is  most  easily  discoverable  hi  the  shafts  of  long  bones,  more  diffi- 
cult when  the  fracture  is  near  a  joint;  in  such  cases  unnatural 
mobility  may  be  demonstrated  more  satisfactorily  by  attempting 
movements  hi  directions  or  to  a  degree  not  permitted  by  the 
normal  range  and  direction  of  action.  In  impacted  fractures  this 
sign  is  altogether  wanting,  unless  the  impaction  is  released  by 
manipulation,  and  it  is  partial  or  wanting  hi  incomplete  fractures 
and  in  most  fissures. 

Spontaneous  Displacement. — When  a  bone  is  broken  it  usually 
fails  to  render  its  normal  support  or  to  stand  its  normal  strain. 
Hence,  when  the  part  affected  attempts  to  functionate  deformity 
is  produced  by  muscular  action  or  by  the  weight  of  the  part. 
If  the  part  is  placed  again  into  its  normal  position  and  left  alone, 
it  is  readily  displaced  by  its  own  weight  or  by  muscular  contraction 
when  the  supports  are  removed.  It  is  superfluous  to  say  that 
spontaneous  displacement  is  absent  in  impacted  fractures  which 
maintain  the  position  determined  by  impaction,  however  abnor- 
mal that  position  may  be.  It  is  wanting,  too,  in  most  fissures 
and  incomplete  fractures,  and  so  slight  in  those  densely  covered 
by  connective  or  muscular  tissue  as  to  be  discovered  only  with 
difficulty.  If  the  palpating  finger  is  placed  on  the  site  of  suspected 
fracture  and  motion,  active  or  passive,  is  attempted  the  fragments 
may  be  felt  to  move,  and  this  demonstrates  unnatural  mobility 
and  perhaps  spontaneous  displacement. 


FRACTURES  387 

Deformity. — Often  this  sign  alone  is  sufficient  to  insure  a  diagno- 
sis of  fracture;  when,  as  is  often  the  case,  the  deformity  is  extreme 
no  doubt  is  left;  if  it  is  slight,  it  must  be  taken  only  as  suggestive, 
unless  it  be  in  a  direction  that  eliminates  the  possibility  of  error. 
Deformity  is  less  valuable  when  in  the  region  of  a  joint,  as  it  might 
signify  either  fracture,  luxation,  or  contusion.  One  must  be  as- 
sure* 1,  too,  that  the  existing  deformity  resulted  from  the  injury, 
for  malingerers  sometimes  claim  that  a  pre-existing  deformity 
resulted  from  a  recent  injury.  The  deformity  may,  in  long  bones, 
be  either  in  the  nature  of  a  deviation  from  the  normal  course,  as 
indicated  by  the  corresponding  member  of  the  opposite  side  of  the 
body,  or  appear  as  shortening,  or,  especially  hi  case  of  bones  en- 
closing a  cavity,  as  a  depression.  If  a  large  hematoma  should 
form  over  the  injured  area  it  often  gives  one  the  impression  that  a 
depression  in  the  bone  exists  when  none  is  present,  or,  on  the 
other  hand,  that  no  depression  of  bone  is  present  when  a  dan- 
gerous and  extensive  depression  exists.  Deformity  may  exist  in 
such  slight  degree  as  to  escape  all  the  coarser  methods  of  diagnosis, 
and  yet  be  demonstrated  by  making  an  incision  down  to  the  bone, 
as  in  cranial  fractures,  or  by  skiagraphy. 

Pain. — Pain  of  itself  is  not  satisfactory  evidence  of  fracture, 
but  the  nature  of  the  pain  may  be  sufficiently  important  to  justify 
a  diagnosis  of  fracture.  If  pain  is  present,  or  is  produced  by  pres- 
sure at  the  site  of  injury,  it  signifies  only  damage  to  the  tissues. 
If  it  is  produced  by  remote  manipulations  of  the  bone,  so  directed 
as  to  move  it  at  the  injured  spot,  it  indicates  probable  fracture. 
For  example,  a  man  receives  a  blow  on  his  chest.  A  bruise  is 
produced;  pressure  on  the  suspected  rib  some  inches  from  the 
contusion  should  not  produce  pain  unless  fracture  is  present.  So, 
in  general,  moderate  motion  of  a  bone  not  fractured,  except  in 
injuries  of  the  joints,  is  not  painful,  but,  if  a  fracture  is  present, 
cither  active  or  passive  motion  produces  pain.  Pain  is  often  very 
suggestive  in  obscure  cases  when  its  severity  is  out  of  all  pro- 
portion to  the  apparent  injury  done.  The  absence  of  pain  also  in 
cases  of  unmistakable  fracture  indicates  that  they  are  pathologic, 
probably  syphilitic. 

Skiagraphy. — The  value  of  the  skiagraph  for  diagnostic  pur- 
poses is  perhaps  greater  here  than  in  any  other  field  of  surgery, 
and  many  injuries  formerly  suspected  to  affect  only  the  soft  parts 
an-  now  shown  to  be  fractures  demonstrating  the  fallibility  of  the 
above-named  methods  of  diagnosis  ami  increasing  considerably  the 
percentage  of  fractures  relative  to  injuries  in  general.  Further- 
more, skiagraphs  show  considerable  displacement  of  fragments 
when  no  such  evidence  appears  from  a  manual  examination,  and 
even  when  the  best  and  formerly  ino-t  -atisfactory  reduction  has 


3gg  PRINCIPLES   OF   SURGERY 

been  made.  If  a  fracture  is  present  and  a  good  picture  can  be 
made,  its  presence  may  be  perfectly  demonstrated;  but,  if  the 
epiphysis  has  not  already  ossified,  it  is  best  to  make  skiagraphs  of 
both  the  normal  and  the  diseased  side  for  comparison.  In  the 
simpler  cases  of  fracture  the  examination  may  be  done  with 
moderate  satisfaction  with  the  fluoroscope;  it  is  much  better, 
however,  to  study  the  negative. 

Ecchymosis  and  Blebs. — In  any  fracture  more  or  less  ecchy- 
mosis  may  be  produced,  and,  as  in  other  deep  injuries,  the  dis- 
coloration may  not  appear  until  some  days  subsequently,  and 
then  be  some  distance  from  the  level  of  the  fracture.  So,  too, 
in  the  larger  fractures  large  blebs  may  appear  under  the  cuticle 
within  a  few  days  after  receipt  of  the  injury. 

Prognosis  of  Fractures. — As  a  rule,  the  outcome  of  fractures 
is  very  gratifying.  The  life  of  an  individual  is  rarely  jeopardized, 
except  when  associated  injuries  are  received  and  when  the  fracture 
is  in  a  very  dangerous  region,  and  in  cases  of  compound  fracture, 
where,  of  course,  the  fracture  plays  a  minor,  and  infection  a  major, 
part.  The  fracture  itself  heals  in  the  vast  majority  of  instances, 
often  in  spite  of  adverse  conditions,  chief  of  which  is  imperfect 
reduction. 

Treatment. — Two  items  constitute  the  treatment  of  simple 
fractures,  namely,  reduction  and  immobilization. 

Reduction. — By  reduction  is  meant  replacement  of  the  bony 
fragments  into  their  normal  position.  It  is  ordinarily  attempted 
by  the  employment  of  extension,  counter  extension,  and  manipula- 
tion. Although  this  plan  is  the  one  commonly  employed,  and 
one  that  will  remain  the  method  of  choice  in  the  hands  of  the 
average  practitioner,  and,  indeed,  in  all  hands,  except  hi  special 
cases  of  fracture  or  under  special  circumstances,  one  must  admit 
that  skiagraphy  shows  almost  invariably  failure  of  perfect  reduc- 
tion even  in  the  most  satisfactory  cases.  Yet  the  results  have 
been  such  as  to  warrant  the  continuance  of  the  method  as  a 
routine  in  general  practice  in  preference  to  the  open  method.  By 
the  term  extension  is  meant  the  traction  made  by  the  surgeon  to 
overcome  the  displacement  due  to  contraction  of  the  muscles.  It 
is  applied  to  the  distal  fragment.  By  counter  extension  is  meant 
the  resistance  against  which  traction  is  made;  it  may  be  simply 
the  weight  of  the  body,  or  this  plus  traction  made  on  the  proximal 
fragment  by  an  assistant  or  by  the  surgeon  himself  in  the  direction 
opposite  to  that  of  extension.  Extension  means  a  pull  on  the 
distal  fragment  away  from  the  body;  counterextension  means  a 
pull  on  the  proximal  fragment  toward  the  body.  For  evident 
reasons,  extension  and  counterextension  are  useful  chiefly,  if 
not  only,  in  the  extremities.  In  certain  cases — e.  g.}  fracture  of 


FRACTURES  389 

the  olecranon  or  the  patella — the  two  fragments  must  be  drawn 
together,  reversing  the  usual  application  of  extension  and  counter- 
extension. 

Manipulation. — By  manipulation  is  meant  such  manual 
changes  in  the  position  of  the  fragments  as  will- force  them  into 
their  proper  places.  Manipulation  is  often  necessary,  in  con- 
junction with  extension  and  counterextension,  in  reducing  frac- 
tures of  the  extremities;  while  in  most  other  fractures  reducible 
l»v  bloodless  methods,  manipulation  is  the  sole  plan  for  reduction. 
The  manipulation  necessarily  varies  with  the  fracture.  In  one 
instance  a  rotation  right  and  left  is  sufficient,  in  another  dis- 
tinct pressure  and  alignment  must  be  done  by  the  manipulating 
hand,  and  in  yet  another  the  fragments  must  be  lifted  into  position 
by  various  mechanical  aids,  as  in  reduction  of  comminuted  fracture 
of  the  nose  by  insertion  of  a  probe  into  the  nostrils,  or  the  lifting 


Fig.  78. — Fractured  forearm  immobilized  by  metal  splint. 

of  a  fractured  zygoma  by  passing  a  large  curved  needle  beneath 
it,  with  which  it  is  lifted  back  into  position. 

Immobilization. — After  a  fracture  is  properly  reduced  it  must  be 
held  hi  proper  position  by  mechanical  supports  until  union  shall 
have  occurred.  This  maintenance  of  position  is  known  as  im- 
mobilization. It  is  accomplished  by  the  employment  of  any 
mechanical  appliance  demanded  by  the  case  in  hand.  It  is  usually 
done  l»y  splints  or  by  plaster-of- Paris  casts,  with  a  proper  padding 
of  the  part,  giving  especial  attention  to  bony  prominences  to 
avoid  pressure  necrosis  and  ulcers.  The  splints  or  cast  should  fit 
the  part  -nugly.  and  should  he  applied  only  tightly  enough  to 
hold  the  fragments  in  reduction.  It  is  wise  in  using  plaster  casts 
not  to  apply  them  until  swelling  has  had  time  to  come  up  and 
subside,  as  the  swelling  will  cause  the  cast  applied  early  to  be- 
come too  tight  and  endanger  the  circulation,  and  its  subsidence 


390 


PRINCIPLES   OF   SURGERY 


will  leave  the  cast  applied  during  the  height  of  swelling,  to  become 
too  loose  and  fail  of  its  purpose.  All  fracture  dressings  should  be 
inspected  several  times  during  the  first  forty-eight  hours  after 
application,  and  the  toes  or  fingers  must  be  left  free,  as  swelling 
or  discoloration  of  them  would  suggest  too  tight  a  dressing.  In 
many  cases  splints  can  be  dispensed  with  to 
advantage  and  some  part  of  the  body  used 
to  serve  a  similar  but  better  purpose;  for 
example,  the  humerus,  when  fractured,  may 
be  immobilized  against  the  chest,  or  the 
fragments  of  a  fractured  elbow  by  sharp 
flexion  of  the  joint  (Jones). 

I  have  already  stated  that  the  object  of 
immobilization  is  to  hold  the  fragments  in 
correct  position.  This  is  frequently  impos- 
sible, even  when  reduction  can  be  done, 
owing  to  the  continual  traction  of  large  mus- 
cles. It  is  especially  difficult  in  fractures  of 
the  femur  of  muscular  subjects.  Hence  ex- 
tension is  often  necessarily  continued  through 
a  part  or  the  whole  period  of  treatment.  It 
is  made  by  the  method  of  Buck,  or  by 
various  plans  which  combine  the  features  of 
immobilization  and  traction  in  the  same 
apparatus. 

If,  for  any  reason,  the  immobilizing  ap- 
paratus becomes  too  lax  it  must  be  changed 
and  refitted.  If  the  fracture  is  compound 
the  usual  requirements  of  wound  dressing 
will  determine  the  frequency  of  change.  If 
plaster  casts  are  used  in  compound  fractures 
a  window  may  be  cut  over  the  wound  to 
allow  dressing. 

The  treatment,  in  general,  of  compound 
fractures  is  that  of  wound  plus  fracture.  It 
is  perhaps  wiser  to  employ  the  open  method 
in  compound  fractures  if  seen  early,  as  no 
great  additional  risk  is  entailed  thereby. 

The  time  required  for  immobilization 
varies  not  only  with  the  fracture,  but  with 

the  age  of  the  patient.  Compound  fractures  unite  more  slowly 
than  simple;  fractures  in  the  young  unite  earlier  than  in  the  old; 
those  of  small  or  thin  bones  sooner  than  in  large  or  heavy  bones. 
Two  weeks  is  about  the  minimum  limit  of  treatment,  and  eight 
to  ten  weeks  may  be  required. 


Fig.  79. — Vicious 
union  of  fractured  fe- 
mur, showing  both  de- 
formity and  great 
shortening. 


FRACTURES  391 

False  Union  and  Vicious  Union. — In  case  insufficient  callus 
is  formed,  or  if  ossification  fails,  the  ends  of  the  fragments  may 
become  united  by  fibrous  tissue,  constituting  a  pseudarthrosis. 
Vicious  union  is  union  of  the  fragments  in  unnatural  position; 
this  often  produces  the  most  bizarre  deformities. 

Delayed  Union  and  Ununited  Fracture. — The  term  "delayed 
union"  is  employed  to  signify  that  union  has  failed  to  occur  within 
the  usual  time  required  for  repair  of  the  given  fracture.  But 
union  is  not  impossible,  and  the  reparative  process  has  not  finished 
its  work.  Ununited  fracture  is  employed  to  signify  that  the 


Fig.  80. — Ununited  fracture  of  lower  fourth  of  right  tibia  and  fibula. 


healing  process,  after  doing  its  utmost  and  having  finished,  has 
failed  to  produce  union. 

It  is  impossible  to  draw  a  distinct  line  between  delayed  union 
an«l  ununited  fracture  except  by  convention.  Ordinarily  we  speak 
of  a  fracture  that  fails  to  unite  in  the  normal  period  or  a  few  weeks 
longer  as  delayed  union;  if  several  months  have  elapsed,  it  is 
spoken  of  as  ununited  fracture.  Granulation  ti->ue  is  still  present 
in  delayed  union;  in  ununited  fracture  the  whole  mass  of  new  tissue 
has  cicatrized,  or,  which  is  to  the  same  purpose,  ossified. 

The  causes  of  these  two  conditions — the  second  is  but  a  later 
stage  of  the  first — is  an  interference,  locally  or  constitutionally, 


392  PRINCIPLES   OF   SURGERY 

with  the  nutrition  of  the  osseous  tissues  or  of  the  osteoblastic 
cells,  imperfect  coaptation,  so  that  the  fractured  ends  may  each 
become  covered  with  an  osseous  callus,  but  the  two  are  found 
out  of  contact,  and,  therefore,  without  union,  or  last  the  inter- 
position of  some  tissue  or  foreign  substance  between  the  ends  of 
the  fragments  that  serves  to  separate  them.  The  causes  in  detail 
are :  improper  nourishment  of  the  body  prior  to  or  after  the  occur- 
rence of  fracture;  this  may  be  due  to  disease  or  improper  diet; 
disease  of  the  fractured  bone;  this  disease  may  come  up  as  a  con- 
sequence of  the  fracture,  especially  if  compound,  or  may  have  been 
present  heretofore.  Pathologic  fractures  are  notoriously  likely 
not  to  heal.  Pregnancy,  while  not  a  pathologic  condition,  favors 
delayed  union  hi  fractures  received  during  its  progress.  Inter- 
ference with  the  local  nutrition,  as  produced  by  the  too  tight  ap- 
plication of  dressings,  or  by  the  prolonged  application  of  cold,  is 
causative  of  these  conditions.  Imperfect  immobilization,  imperfect 
reduction,  and  the  interposition  of  foreign  bodies  or  fragments  of 
tissue,  commonly  bone,  periosteum,  muscle,  fat,  or  fascia,  are  by 
far  the  most  frequent  local  causes  of  delayed  union.  Infection 
invariably  delays  the  healing  process  and  may  result  in  failure  of 
union.  The  frequency  of  delayed  union  in  compound  fractures  is 
thus  explained,  and  the  treatment  of  fractures  should  be  prolonged 
on  occasions  of  this  kind. 

Treatment  of  Delayed  Union  and  Ununited  Fracture. — The 
first  item  in  treatment  is  to  determine  the  cause  of  the  failure  and 
correct  it.  A  thorough  investigation  will  rarely  fail  to  show  what 
the  cause  is,  but  frequently  it  is  impossible,  as  in  cases  of  pregnancy 
and  in  pathologic  fractures,  especially  if  due  to  metastases  from 
malignant  tumors,  to  remove  the  cause.  Certain  pathologic 
cases  are  manifestly  hopeless.  If  no  foreign  body  is  interposed 
between  the  fragments,  and  if  no  local  pathologic  process  aside  from 
the  traumatism  is  present,  the  diet  may  be  corrected,  proper  ad- 
justments of  splints  may  be  made,  and  the  fragments  may  be 
incited  to  further  effort  by  vigorously  grinding  or  manipulating 
the  fragments  against  each  other  while  the  patient  is  anesthetized. 
If  diet,  splints,  rest,  and  proper  reduction  fail,  especially  if  they 
fail  after  a  second  attempt,  further  tentative  treatment  should 
not  be  employed;  incise,  remove  the  cause,  adjust  accurately,  and 
hold  in  position  by  Lane's  plates,  screws,  pegs,  wire,  bone,  or  cat- 
gut. This  should  be  the  plan  in  all  ununited  fractures;  the  others 
mentioned  are  a  waste  of  time. 

Treatment  of  Fractures  by  the  Open  Method. — Of  recent  years, 
thanks  largely  to  the  work  of  Mr.  Arbuthnot  Lane,  of  London,  the 
treatment  of  fracture  by  the  open  plan  is  growing  rapidly  in 
favor.  Personally,  I  believe  that  where  the  work  can  be  done 


FRACTURES  393 

under  proper  environment  it  is  much  preferable  to  the  bloodless 
plan  in  the  majority  of  serious  fractures,  for  by  it  the  fracture  can 
be  reduced  under  ocular  inspection,  and  can  be  immovably  fixed 
in  reduction;  pain  due  to  subsequent  movement  of  fragments  is 
eliminated,  deformity  and  shortening  do  not  occur,  and  the  time 


Fig.  81. — Fractured  bone  immobilized  by  Lane's  plate. 

of  union  is  materially  shortened.  It  is  the  method  of  choice  in 
fractures  of  the  larger  bones,  and  can  be  done  easily  and  safely  by 
any  one  acquainted  with  his  anatomy  and  with  aseptic  methods. 
Infection  must  be  guarded  against  absolutely.  The  material  em- 
ployed to  unite  the  fragments  if  metallic,  as  Lane  recommends, 
should  be  proof  against  corrosion  in  the  tissues. 


CHAPTER    XXVI 
LUXATIONS    OR    DISLOCATIONS 

A  LUXATION,  or  dislocation,  is  the  displacement  of  one  or  more 
bones  of  an  articulation  from  the  normal  relation  to  the  remaining 
bones  which  go  to  constitute  the  articulation. 

Luxations  may  be  partial  or  complete.  In  the  former  the  dis- 
placed articular  surface  is  not  completely  removed  from  its  fellow; 
in  the  latter  it  is. 

Classification. — The  classification  of  luxations  is  as  follows: 
Simple  luxation  is  one  hi  which  there  is  no  further  traumatism 
done  than  that  necessary  to  permit  the  dislocation.  Compound 
dislocation  is  one  associated  with  a  wound  leading  to  the  joint  sur- 
face or  through  which  the  dislocated  bone  protrudes.  A  com- 
plicated dislocation  is  one  associated  with  another  important 
lesion  in  the  same  region.  A  unilateral  dislocation  is  a  dislocation 
of  a  median  bone  on  one  side;  a  bilateral  dislocation  is  the  dislo- 
cation of  a  median  bone  on  both  sides. 

Cause. — The  production  of  luxations,  like  fractures,  is  largely 
traumatic,  the  force  being  applied  hi  such  a  manner  as  to  cause 
a  desertion  of  one  articular  surface  by  another.  The  traumatism 
may  be  solely  an  extraneous  force,  solely  muscular  effort,  or  the 
two  combined.  There  are  certain  positions  of  the  elements  of  a 
joint  and  directions  of  force  which  favor  the  production  of  dis- 
location, owing  to  the  structure  of  the  joint.  Hence,  for  each  joint 
there  are  certain  possible  dislocations,  some  of  which  are  much 
more  frequent  than  others.  For  example,  dislocation  of  the  head 
of  the  humerus  is  usually  forward,  under  the  outer  end  of  the 
clavicle. 

Besides  the  above  given  causes,  pathologic  processes  which 
render  the  ligamentous  or  muscular  support  of  a  joint  less  efficient 
favor  dislocation.  A  frequent  example  is  luxation  of  the  hip- 
joint  from  insignificant  force  in  children  who  have  suffered  from 
typhoid  fever.  Occasionally  dislocations  occur  in  the  unborn 
fetus.  Their  causation  is  not  clear. 

In  simple  luxations  the  damage  done  is  comparatively  slight. 
The  capsule  and  the  ligaments  are  more  or  less  lacerated,  but  the 
articular  surfaces  are  not  impaired.  While  dislocations  affect 
bones,  the  real  damage  done  is  usually  to  the  soft  structures  only. 

Diagnosis. — As   in   fractures    there   have   been   three   time- 

394 


LUXATIONS   OR   DISLOCATIONS  395 

honored  diagnostic  signs,  so  in  dislocations  there  are  three,  namely, 
absence  of  crepitus,  preternatural  immobility,  and  absence  of 
tendency  for  the  displacement  to  recur  after  reduction,  i.  e., 
absence  of  spontaneous  displacement.  It  is  easy  to  understand 
that  the  difference  between  the  symptoms  of  dislocations  and  of 
fractures,  therefore,  depends  on  the  nature  of  the  lesion  and  on 
the  structures  affected  by  it.  In  addition  to  the  above  symptoms, 
deformity  is  almost  invariably  the  rule,  and  if  the  deformity  is  not 
present  it  is  represented  by  the  assumption  of  some  particular 
attitude  by  the  joint  affected,  and  the  maintenance  of  this  atti- 
tude in  spite  of  efforts,  either  actively  or  passively,  to  correct  it. 
To  determine  whether  deformity  is  present  in  a  joint  as  the  result 
of  traumatism,  it  is  wiser  always  to  compare  it  with  the  corre- 
sponding joint  of  the  opposite  side.  In  many  cases  such  com- 
parison will  render  diagnosis  certain  from  inspection  alone.  How- 
ever, it  is  often  necessary  to  measure  the  parts  on  the  two  sides  of 
the  body,  by  which  means  we  are  enabled  to  determine  whether 
the  injury  has  caused  lengthening  or  shortening.  The  preternat- 
ural immobility  produced  in  dislocation  is  due  not  only  to  the  fact 
that  one  articular  surface  has  partially  or  completely  deserted  its 
fellow,  but  to  the  further  fact  that  the  moment  such  desertion 
occurs  the  range  of  movement  is  materially  limited  by  rigidity  of 
the  muscles  which  move  the  joint.  In  addition  to  the  above- 
named  signs  of  dislocation  pain  is  a  constant  and  frequently  a 
very  important  sign.  As  in  fractures,  this  pain  is  increased  by 
attempted  movements,  but  not  to  the  same  degree.  By  virtue  of 
the  fact  that  one  bone  has  been  displaced  from  another,  a  certain 
amount  of  injury  is  necessarily  done  to  the  soft  parts,  consequently, 
swelling  is  almost  invariably  present  hi  dislocation,  and  occasionally 
it  is  extreme.  It  usually  requires  several  hours  for  the  swelling  to 
reach  its  maximum,  an  important  fact  to  be  remembered  relative 
to  the  time  best  suited  to  examination  and  reduction.  Discolora- 
tion of  the  skin  surrounding  the  joint  and  for  some  distance  below 
it  frequently  is  observed,  due  to  the  escape  of  blood  into  the  sub- 
cutaneous tissues. 

One  frequently  finds  cases  of  ancient  luxation,  and  occasionally 
a  recent  luxation,  which  has  been  mistakenly  diagnosed  all  other 
kinds  of  lesions  capable  of  affecting  the  joint.  They  are  di- 
agnosed as  synovitis,  arthritis,  and  especially  as  rheumatism — 
mistakes  which,  if  the  history  of  the  case  is  taken  into  considera- 
tion and  if  a  thorough  examination  of  the  part  is  made,  should 
occur  far  less  frequently  than  they  do.  In  cases  where  there  is 
doubt  in  the  physician's  mind,  it  can  very  easily  be  dispelled  by  a 
satisfactory  skiagraph,  which  embraces  not  only  the  joint  affected, 
but  its  fellow  on  the  opposite  side. 


396  PRINCIPLES   OF   SURGERY 

The  most  confusing  lesion  from  which  luxations  have  to  be  dis- 
tinguished are  fractures  close  to  the  joint,  such  as  occur  in  the 
surgical  neck  of  the  humerus  and  in  the  neck  of  the  femur.  Ep- 
iphyseal  separation  is  also  very  difficult  to  differentiate  from 
dislocations. 

Prognosis. — The  results  of  proper  treatment  of  dislocations  is, 
on  the  whole,  very  satisfactory,  much  more  so,  in  fact,  than  the 
treatment  of  fractures  by  the  ordinary  closed  method.  Failure, 
however,  to  reduce  a  dislocation  within  a  reasonable  time  after  its 
occurrence  results  hi  more  or  less  complete  loss  of  the  joint,  and 
may  prove  disastrous  to  the  patient  from  an  economic  stand- 
point; for  after  a  dislocation  has  occurred  the  joint  surfaces  may 
be  more  or  less  completely  destroyed  by  the  formation  of  new 
tissue  over  them,  and  the  normal  contour  of  the  joint  so  altered 
that  they  will  not  fit  each  other  even  when  reduction  is  made. 

Recurrent  Dislocations. — Certain  dislocations  are  capable  of 
recurring  repeatedly,  once  they  have  been  produced,  even  though 
the  treatment  at  the  time  was  satisfactory.  This  is  due  to  the 
fact  that  the  structures  normally  holding  the  joints  in  position 
have  been  so  altered  by  the  first  injury  that  they  are  no  longer 
capable  of  maintaining  the  bones  in  their  relative  position,  and  so 
allow  dislocation  to  occur  as  a  result  of  slight  force  or  simply  of 
movements  of  the  joint  to  an  extreme  range.  The  joints  in  which 
recurrent  luxations  occur  most  frequently  are  the  shoulder-  and 
the  temporomaxillary  joints.  When  they  do  occur  they  are 
always  of  the  same  type  as  the  original  dislocation. 

Treatment. — The  object  of  treatment  of  a  dislocation  is  to 
replace  the  bones  in  their  normal  position  with  as  little  additional 
damage  to  the  surrounding  structures  as  possible,  and  to  maintain 
them  in  this  position  until  the  opening  hi  the  capsule  through 
which  dislocation  occurred  and  the  ligaments  surrounding  the 
joint  may  be  adequately  repaired.  The  rules  for  reduction  of  dis- 
locations vary  for  the  different  joints  affected,  and,  while  extension 
and  counterextension  may  be  necessary,  the  chief  factor  in  reduc- 
tion is  manipulation,  which  should  be  of  such  a  nature  as  to  place 
the  bones  constituting  the  joint  in  the  relative  position  occupied 
by  them  at  the  time  the  dislocation  occurred,  and  then  to  move 
them  in  a  direction  opposite  to  that  taken  by  them  during  the 
displacement  (Bigelow).  Placing  them  in  the  position  occupied 
at  the  time  of  dislocation  relaxes  the  capsule  and  brings  the 
articular  surface  opposite  the  rent  through  which  it  escaped. 
The  movement  of  the  bones  hi  the  direction  opposite  that  of 
escape  causes  the  dislocated  one  to  return  through  the  capsule  to 
its  normal  position.  Usually  one  may  determine  that  a  disloca- 
tion has  been  reduced  by  feeling  a  distinct  knock  of  the  bone  as  it 


LUXATIONS    OB   DISLOCATIONS  397 

slips  back  into  place,  and  may  satisfy  one's  self  that  reduction  is 
accomplished  by  manipulation  of  the  joint  through  its  normal 
range  of  movement.  Of  course,  the  deformity  disappears  when 
reduction  is  accomplished,  except  such  as  results  from  swelling. 

After  reducing  a  dislocation  the  joint  is  to  be  restricted  in 
motion  and  limited  in  use  for  a  period  of  two  to  three  weeks, 
and,  if  it  is  unnecessary  to  immobilize  it,  the  patient  should  be 
cautioned  against  extreme  ranges  of  movement  for  the  same 
time. 

Recurrent  dislocations  may  be  corrected  by  incision  into  the 
joint  and  correction  of  the  lesion  permitting  it;  ancient  disloca- 
tions also  frequently  require  to  be  corrected  by  opening  the 
joint. 


CHAPTER    XXVII 
THROMBOSIS  AND  EMBOLISM 

THROMBOSIS 

Definition. — The  term  "thrombosis"  is  used  to  signify  coagula- 
tion of  blood  within  the  vessels  during  life.  It  is  a  very  common 
pathologic  process,  and,  produced  as  it  is  by  pathologic  condi- 
tions, by  surgical  procedures,  and  as  a  result  of  physiologic  dis- 
turbance of  the  circulation  or  chemical  alterations  of  the  blood, 
it  is  a  condition  that  concerns  the  surgeon  very  nearly. 

Composition. — A  thrombus  may  be  made  up  of  all  the  solid 
elements  of  the  blood,  due  to  coagulation  and  escape  of  the  serum, 
or  it  may  be  made  up  of  only  a  part  of  these  elements,  namely,  the 
blood-platelets,  white  blood-cells,  and  fibrin,  any  one  of  which 
may  predominate.  The  former  produces  primarily  a  red  thrombus 
and  occurs  when  the  blood  is  stagnant,  and  the  latter  a  white 
thrombus,  which  is  the  type  produced  while  the  blood  is  still 
circulating. 

Causes. — The  causes  of  thrombosis  are  very  diversified,  but 
fundamentally  produce  the  condition  as  a  consequence  of  certain 
changes  common  to  them  all.  First,  obstruction  of  the  lumen  of  a 
vessel,  be  it  vein  or  artery,  will  cause  the  appearance  of  a  throm- 
bus; it  may  extend  from  the  site  of  obstruction  to  the  lumen  of  the 
nearest  branch  leading  from  or  into  it,  but  in  ligation  of  arteries 
is  often  found  to  appear  only  at  the  ligated  point,  if  at  all.  Such 
thrombi  are  produced  by  ligation  of  blood-vessels  in  surgical  work. 
Second,  increase  in  the  size  of  the  blood-vessel,  such  as  happens 
in  varicose  veins,  favors  production  of  thrombi.  Third,  infectious 
processes  and  traumatism,  which  interfere  with  the  structure  or 
the  function  of  the  intima,  produces  them.  Fourth,  they  are 
favored  by  a  circulation  such  as  is  found  in  very  weakened  indi- 
viduals or  in  patients  whose  heart  action  is  inadequate.  Fifth, 
by  general  conditions,  such  as  marasmus,  chlorosis,  hydremia. 
Thrombosis  cannot  occur  unless  there  is  some  change  in  the 
blood  itself  or  in  the  lining  membrane  of  the  vessel.  All  other 
factors  are  predisposing.  The  surgical  conditions  in  which  thrombi 
are  most  likely  to  appear  are  traumatism,  whether  operative  or 
accidental,  especially  if  it  affects  the  blood-vessels  themselves, 

398 


THROMBOSIS   AND    EMBOLISM  399 

infections,  varices,  and  operations,  particularly  in  the  pelvis  or 
lower  abdomen,  in  patients  whose  vitality  is  much  impaired. 
They  are  found  particularly  as  a  result  of  infection  in  regions  well 
supplied  with  venous  plexuses  or  in  sinuses,  such  as  the  uterine 
and  intracranial.  If  a  thrombus  forms  in  the  lumen  of  a  vessel 
through  which  the  blood  is  still  circulating  it  may  be  of  the  gray 
or  white  variety  and  arranged  in  concentric  layers.  Sometimes 
these  layers  are  alternately  red  and  white. 

Symptoms. — Since  thrombi  may  form  hi  any  vessel,  whatever 
its  size  and  importance,  or  lack  of  importance,  it  is  easy  to  see 
that  the  symptomatology  attendant  upon  thrombosis  varies  all 
the  way  from  the  most  insignificant  disturbances  to  the  most 
violent.  When  thrombi  occur  hi  small  unimportant  vessels,  no 
symptoms  or  signs  appear;  the  same  is  true  when  they  appear  in 
larger  vessels,  provided  there  is  an  adequate  collateral  circulation. 
If  thrombosis  occurs  hi  a  terminal  vessel,  or  in  one  which  has  no 
adequate  collateral  circulation,  the  most  direful  immediate  and 
remote  results  may  follow.  But  the  symptoms  even  here  are 
determined,  not  so  much  by  the  fact  that  a  blood-vessel  has  been 
occluded,  but  because  the  circulation  is  shut  off  from  an  important 
structure  or  region.  The  particular  region  affected,  too,  gives 
color  to  the  symptomatology;  for  example,  thrombosis  hi  the 
cerebral  or  dural  vessels  produces  one  group  of  symptoms,  throm- 
bosis of  the  mesenteric  vessels  another  group,  and  they  are  de- 
termined by  the  fact  that,  in  the  first  instance,  brain  tissue  is 
disturbed,  and,  in  the  second,  the  alimentary  tract.  Thrombosis 
of  an  artery  furnishing  the  main  blood-supply  to  an  extremity 
produces  pain  and  pallor  in  the  region  whose  blood-supply  is  cut 
off.  If,  however,  the  thrombosis  occurs  in  a  vein,  swelling  and 
cyanosis  of  the  extremity  are  produced,  giving  us  one  type  of 
phlegmasia  alba  dolens,  or  milk-leg,  a  condition  formerly  seen 
quite  frequently  as  a  consequence  of  unclean  obstetric  work. 
Whether  the  vein  or  artery  of  the  extremity  be  obstructed,  gan- 
grene may  result,  as  has  been  explained  hi  the  chapter  devoted  to 
that  subject.  In  either  instance  the  temperature  of  the  part  is 
mati'rially  reduced. 

Win -ii  thrombosis  occurs  in  superficial  veins  or  in  the  veins  of 
extremities  the  veins  may  be  felt  as  a  hard  cord,  and  are,  hi  all 
probability,  tender.  If  it  is  due  to  an  infectious  process  signs 
of  thrombophlebitis  are  present.  In  the  hemorrhoidal  plexus 
thromboses  are  quite  a  common  ocmrrenre,  and  may  be  found 
in  patients  who  have  had  no  hemorrhoids,  but  are  more  frequently 
found  hi  patients  who  have  a  history  of  this  condition,  and  are 
kno\vn  as  thromhotie  hemorrhoids.  Thrombotic  hemorrhoids 
are  capable  of  producing  the  most  excruciating  pain  and  are  fre- 


400  PRINCIPLES   OF   SURGERY 

quently  very  tender,  being  felt  as  firm,  roundish  tumors,  situated 
either  hi  the  external  or  the  internal  hemorrhoidal  plexus. 

Though  thrombosis  may  occur  hi  any  artery,  vein,  or  even  the 
capillaries  of  the  circulation,  and  within  the  cavity  of  the  heart, 
there  are  certain  sites  which  afford  the  greatest  number  of  in- 
stances. These  sites  are  the  veins  of  the  lower  extremity,  espe- 
cially the  long  saphenous  and  its  radicles,  which  are  frequently 
affected  by  the  favoring  condition  of  varicosis — the  upper  ex- 
tremity is  rarely  affected — the  rectum,  the  pelvic  veins  of  women, 
the  uterine  sinuses,  which  are  most  frequently  involved  hi  connec- 
tion with  abortions  or  child-birth,  especially  if  infection  of  the 
parturient  canal  has  occurred,  the  cerebral  vessels,  and  the  dural 
sinuses.  Occasionally  the  mesenteric  artery  or  vein,  usually  the 
superior,  is  thrombosed,  with  resultant  pains,  distention,  and 
gangrene  of  the  intestines,  attended  with  symptoms  of  a  violent 
mtra-abdominal  disturbance  and  frequently  with  bloody  dis- 
charge hi  the  stools. 

There  are  no  constitutional  symptoms  attendant  upon  throm- 
bosis, except  such  as  depend  upon  the  causative  or  resultant  condi- 
tion, as  has  already  been  shown.  If  infection  be  the  cause,  corre- 
sponding general  symptoms  of  infection  may  be  present.  In  those 
cases  where  thrombi  appear  in  vessels  necessary  to  the  mainten- 
ance of  life  sudden  death  may  occur.  Thus,  a  ball  thrombus  may 
develop  in  the  heart  and  suddenly  block  the  auriculoventricular 
opening,  and  thrombi  in  the  dural  sinuses  and  the  vessels  of  the 
brain  may  produce  instantaneous  death  or  paralysis. 

Diagnosis. — Many  thrombi  appear  and  disappear  with  no 
symptoms  or  signs  to  give  evidence  of  their  existence.  Such  are 
continually  attendant  upon  acute  inflammatory  processes,  ab- 
scesses, and  traumatism.  Often  the  symptomatology  may  be 
obscure,  but,  if  taken  hi  connection  with  the  presence  of  causes 
likely  to  produce  thrombosis,  may  lead  to  a  suspicion  of  the  true 
nature  of  the  lesion,  particularly  when  the  symptoms  are  referable 
to  a  region  frequently  affected  by  this  condition. 

Course  of  Thrombosis. — Manifestly,  those  thrombi  which  are 
produced  by  infection  such  as  appear  in  thrombophlebitis  and 
thrombo-arteritis  are,  other  things  being  equal,  most  dangerous. 
This  is  true  not  only  because  the  infection  in  and  of  itself  is  cap- 
able of  causing  an  indefinite  extension  of  the  clot,  but  because 
they  contain  bacteria  which  may  at  any  time  reach  the  general 
circulation  and  produce  pyemia. 

Either  infected  or  simple  aseptic  thrombi  may  originate  in  a 
small  vessel  of  no  importance,  and,  under  favorable  circumstances, 
gradually  or  rapidly  extend  into  the  lumen  of  the  most  important 
channels  of  circulation.  So  a  thrombus  may  extend  from  the 


THROMBOSIS    AND   EMBOLISM  401 

upper  limit  of  the  vena  cava  to  the  small  radicles  in  the  foot  as 
one  continuous  clot,  and  thus  interfere  with  the  total  return  of 
blood  from  the  lower  half  of  the  body. 

One  of  the  dangerous  accidents  resulting  from  thrombosis  is 
liberation  of  a  portion  of  the  clot  in  the  form  of  an  embolus,  which, 
by  its  lodgment  hi  an  important  vessel,  may  produce  sudden 
death  or  alarming  symptoms.  This  accident  is  favored  by  active 
or  passive  motion  or  by  massage  or  manipulation  of  the  part  in 
which  the  thrombus  forms;  it  is  favored,  too,  by  allowing  the 
patient  to  get  out  of  bed  and  resume  his  active  duties  too  early 
after  operation,  especially  if  the  operation  is  done  hi  the  lower  part 
of  the  abdomen  or  in  the  pelvis.  Even  the  most  insignificant 
intra-abdominal  and  pelvic  operation,  such  as  interval  appen- 
dectomy or  shortening  of  the  round  ligaments,  has  been  known 
to  result  fatally  from  this  source.  The  practical  conclusion  to  be 
drawn  from  this  is  that  patients  should  not  be  allowed  to  get  up 
from  such  an  operation  short  of  ten  days,  except  when  the  demands 
for  such  a  course  outweigh  the  chance  of  danger  from  this  source. 
Thrombi  do  not  become  fixed  until  ten  days  after  their  formation, 
ami.  therefore,  if  the  patient  is  allowed  to  exercise  too  early  it  will 
be  an  easy  matter  to  dislodge  the  thrombi  and  produce  blockage 
cit  her  of  the  right  heart  or  of  the  pulmonary  artery.  Many  sudden 
deaths  from  this  source  are  recorded  in  the  hospitals  where  post- 
mortems are  habitually  held.  These  thrombi  frequently  form  in 
the  vessels  of  the  side  opposite  the  operation. 

Soon  after  their  formation  within  a  blood-vessel  thrombi  may 
Liu  in  to  organize  by  the  outgrowth  of  new  blood-vessels  and 
fibn (blasts  from  the  lining  cells  of  the  vessels,  following  the  same 
steps  taken  by  the  healing  process  under  normal  conditions.  If 
the  clot  is  red  the  hemoglobin  gradually  disappears  from  it  and  it 
becomes  a  whitish  color,  yellow,  or  grayish;  finally,  the  whole 
thrombus  is  converted  into  cicatricial  tissue  and  the  lumen  of  the 
vessel  obliterated,  so  that,  instead  of  the  normal  vessel,  only  a 
fibrous  cord  is  left  as  its  representative.  -Occasionally  after  a 
process  of  this  kind  recanalization  of  the  vessel  occurs,  which 
allows  it  to  carry  a  part  of  its  normal  quantity  of  blood,  although 
the  lumen  is  jMTmanently  somewhat  constricted. 

Calcification  may  take  place  in  thrombi  and  vein-stones,  or 
phleholiths,  be  produced.  These  are  seen  rather  frequently  in  the 
pelvic  vein-  and  in  varicosjs  of  the  lower  extremity.  In  the  former 
situation  they  occasionally  appear  in  skiagraphs,  and  lead  to  the 
mistaken  diagnosis  of  ureteral  calculi  lodged  in  this  position. 

Disintegration  of  thrombi  may  occur  as  the  result  of  fatty  de- 
generation or  from  the  peptoni/.ing  action  of  bacteria,  and  lead  to 
the  escape  of  the  whole  mass  or  a  considerable  part  of  it  into  the 

26 


402  PRINCIPLES   OF   SURGERY 

general  circulation  and  lodgment  of  the  particles  in  various 
parts  of  the  body,  and  these  emboli,  if  they  are  septic,  establish 
pyemia. 

Prognosis. — Presence  of  simple  thrombi  in  the  smaller  unim- 
portant arteries  is  of  little  consequence,  but  the  presence  of  a 
thrombus  in  a  vein  carries  with  it  necessarily  always  more  or  less 
risk  to  life  or  limb,  and  this  danger  increases  with  the  size  and 
importance  of  the  vessel,  and  is  at  its  worst  when  the  cause  is  one 
of  the  pyogenic  bacteria. 

Treatment. — Prevention  of  thrombi  should  be  accepted  by  the 
surgeon  and  the  physician  as  a  most  imperative  duty.  In  all  cases 
the  utmost  care  should  be  used  in  manipulating  the  tissues  so  as 
to  prevent  damage  to  the  lining  of  the  blood-vessels,  especially 
in  the  dangerous  regions.  When  it  is  possible  the  patient's  general 
condition  should  be  brought,  by  pre-operative  treatment,  as  nearly 
to  normal  as  possible,  so  that  operation  may  be  undertaken  under 
the  most  favorable  circumstances.  Where  this  cannot  be  done 
prior  to  operation,  all  patients  whose  condition  favors  the  appear- 
ance of  thrombosis  should  be  treated  in  such  manner  as  to  main- 
tain their  circulation  as  nearly  normal  as  possible.  It  is  super- 
fluous to  say  that  in  all  cases  the  utmost  care  should  be  used  to 
prevent  infection. 

When  thrombi  have  developed,  the  greatest  care  must  be 
exercised  not  to  allow  anything  to  be  done  that  could  displace 
the  thrombus  as  a  whole  or  hi  parts,  to  maintain  the  circulation 
of  the  part  as  perfectly  as  possible,  and  to  support  the  life  of  the 
part  by  elevation  and  the  application  of  artificial  heat  until 
adequate  collateral  circulation  can  be  established.  Absolute  rest 
in  bed  must  be  enforced  upon  these  patients,  and  they  should  have 
an  attendant  to  change  then1  position,  so  as  to  avoid  all  physical 
effort. 

If  a  thrombus  is  septic,  or  if  it  continues  to  spread,  the  vessel 
containing  it  should  be  ligated  above  and  below  the  clot,  and  an 
incision  made  into  the  lumen  of  the  vessel  between  these  ligatures, 
the  clot  cleaned  out,  and  drainage  instituted.  Complete  hyster- 
ectomy may  be  necessary  in  septic  thrombosis  of  the  uterine 
arteries,  and  has,  hi  fact,  been. recommended  and  practised  by 
Trendelenburg  hi  these  cases  to  prevent  general  sepsis.  If  in  a 
given  case  of  thrombosis  it  is  impossible  to  ligate  the  vessel  on 
each  side  of  the  clot,  as  frequently  happens  in  thrombophlebitis 
of  the  dural  sinuses,  it  is  necessary  to  open  the  vessel,  clean  out 
the  infected  clot,  and  control  hemorrhage  by  tamponade. 

The  general  nutrition  of  the  patient  must  be  carefully  looked 
to,  and  an  effort  made  by  feeding,  stimulation,  and  tonics  to  bring 
both  the  blood  and  the  circulation  to  their  normal  standing. 


THROMBOSIS    AND    EMBOLISM  403 


EMBOLISM 

An  embolus  is  a  foreign  substance — solid,  liquid,  or  gaseous — 
which  is  carried  in  the  blood  and  lodges,  producing  a  more  or  less 
complete  occlusion  of  the  vessel  at  the  point  of  lodgment. 

Emboli,  of  course,  cannot  form  from  substances  which  dis- 
solve in  the  blood  immediately  on  gaining  access  to  the  vessels. 
They  must,  therefore,  be  at  the  time  undissolved  in  the  blood. 
They  are  derived  from  two  sources,  namely,  from  within  the 
blood-vessels,  which  are  called  endogenous,  or  from  without  the 
blood-vessels,  which  are  called  exogenous,  emboli.  Either  of  these 
two  types  may  be  bland  or  active.  By  a  bland  embolus  is  meant 
one  which  is  incapable  of  doing  harm  to  the  tissues  or  the  body 
aside  from  its  mechanical  action.  It  is  sterile  or  aseptic  and,  at 
the  same  time,  made  up  of  non-vital  tissue.  Active  emboli,  on  the 
other  hand,  are  capable  of  causing  harm  aside  from  their  mechan- 
ical action  of  blocking  blood-vessels.  They  are  either  made  up  of 
living  tissue  or  pathologic  cells,  of  bacteria  or  of  parasites  which 
have  gained  access  to  the  circulation.  After  lodging  in  the  vessels 
these  active  emboli  produce  an  infection  at  the  point  of  lodgment, 
a  metastatic  tumor  or  other  lesion. 

Sources  of  Emboli. — By  far  the  great  majority  of  emboli 
originate  from  within  the  vessels  themselves,  and  of  these  prob- 
ably the  greatest  number  are  derived  from  thrombi  that  have  been 
formed  in  the  veins  or  arteries  and  have  been  displaced  by  one 
means  or  another  and  admitted  into  the  general  circulation. 
Arteriosclerosis  is  another  favorite  condition  for  the  development 
of  emboli,  not  only  because  thrombi  are  likely  to  form  in  arterio- 
sclerotic  vessels,  but  for  the  further  reason  that  the  pathologic 
changes  consequent  upon  arteriosclerosis  may  liberate  solid  par- 
t  i«  li  -  \\hich  lodge  and  produce  embolism.  Endocarditis,  especially 
of  the  chronic  type,  is  another  favorite  antecedent  of  embolism. 
The  emboli  coming  from  the  valves  particularly,  after  the  same 
fashion  as  arteriosclerotic  emboli,  are  formed  hi  that  condition. 
Malignant  tumors  are  notorious  for  their  production  of  metas- 
tases  remote  from  their  primary  focus,  and  it  may  be  accepted  that 
most  of  these  remote  met.-i-i:i>es  develop  as  a  consequence  of  small 
parti< -1. -  of  tumors  which  have  infiltrated  the  vessels,  being  liber- 
ated from  the  primary  growth  and  distributed  through  the  cir- 
culation. It  must  not  be  understood,  however,  that  emboli  from 
malignant  tumors  invariably  produce  metastases,  for  an  embolus 
from  tin-  source  is  capable  of  producing  the  same  dire  re-ult-  as 
any  other  type  of  embolus.  The  fat  of  the  patient's  body  fre- 
quently causes  eniboli>m.  e<pecially  in  connection  with  fractures, 
particularly  of  the  shafts  of  the  long  bones,  the  source  of  the-e 


404  PRINCIPLES   OF   SURGERY 

emboli  being  chiefly  the  bone-marrow.  Fat  emboli  are  occasionally 
observed  from  lesions  which  do  not  affect  the  bone,  as  in  amputa- 
tions of  the  breast  or  other  operative  procedures.  Emboli  are  fre- 
quently derived  from  suppurative  and  inflammatory  processes  and 
from  infected  wounds,  being  due  to  the  dislodgment  of  thrombi 
or  to  the  escape  of  a  part  of  the  contents  of  a  suppurative  or  other 
pathologic  process  into  the  circulation.  Rarely  bacteria  alone 
are  clumped  together  into  such  masses  as  are  capable  of  lodging 
in  the  smaller  capillaries  and  producing  distinct  emboli.  Air 
emboli,  while  not  a  common  type,  are  certainly  a  danger,  par- 
ticularly in  operations  or  wounds  that  affect  the  region  of  the  neck 
or  the  sinuses  of  the  dura  and  in  cases  where  hypodermoclysis 
or  other  intravenous  medication  is  carelessly  done.  They  have 
been  known  to  occur  as  a  consequence  of  failure  on  the  part  of 
an  attendant  to  remove  all  air  from  the  hypodermic  syringe  prior 
to  making  an  injection.  Chemical  substances  insoluble  in  the 
blood,  which  are  injected  hypodermically  or  subcutaneously,  such 
as  oils  and  emulsions,  of  which  the  most  frequently  used  are  the 
preparations  of  mercury  employed  in  the  treatment  of  syphilis,  if 
injected  into  a  vein,  may  cause  embolism.  Injections  of  paraffin 
for  cosmetic  purposes  occasionally  give  rise  to  paraffin  em- 
bolism. 

The  Pathologic  Consequences  of  Embolism. — Necessarily  the 
immediate  result  of  embolism  is  an  interruption  of  the  circulation 
through  the  vessel  in  which  the  embolus  is  lodged.  This  shuts  off 
the  circulation  from  the  region  beyond,  the  behavior  of  which 
depends  largely  on  the  amount  of  collateral  circulation  present  or 
possible,  as  has  already  been  discussed  under  Thrombosis.  If 
the  circulation  is  cut  off  completely  from  an  extremity,  gangrene 
will  result.  If  it  is  cut  off  from  a  certain  portion  of  tissue,  as  hap- 
pens in  the  lungs,  brain,  liver,  kidney,  spleen,  intestines,  an  infarct 
may  result,  and  be  either  of  the  red  or  the  white  variety,  depend- 
ent upon  the  individual  case.  Degeneration  (fatty)  of  the  area 
whose  blood-supply  is  shut  off  may  occur,  and  in  this  instance,  as 
well  as  in  the  case  of  infarction,  new  tissue  formation  may  take 
place  from  surrounding  healthy  structures  and  replace  the  devital- 
ized area  by  connective  tissue,  which,  when  it  is  formed,  appears 
of  a  size  many  times  smaller  than  the  original  lesion.  At  the  site 
of  lodgment  of  the  embolus  the  circulation  is  checked  or  stopped 
in  the  vessels  affected,  and,  of  course,  thrombosis  develops  at  the 
site  of  lodgment  of  the  embolus.  So  true  is  this,  that  after  a  few 
days  it  is  frequently  impossible,  or  at  least  difficult,  to  say  whether 
the  original  condition  was  embolism  or  thrombosis,  owing  to  the 
fact  that  the  embolus  is  imbedded  in  the  thrombus  or  has  entirely 
disappeared  from  the  point  of  lodgment.  The  previous  state- 


THROMBOSIS    AND    EMBOLISM  405 

ments  are  true  for  all  forms  of  emboli,  and  they  represent  the 
whole  truth,  so  far  as  bland  or  aseptic  emboli  are  concerned.  If 
the  embolus  is  active,  however,  certain  changes  may  develop  hi 
addition  to  the  above,  dependent  upon  the  nature  of  the  embolus 
and  upon  the  favorableness  of  the  structure  in  which  it  lodges  for 
its  further  growth  and  action.  Doubtless,  many  small  emboli 
made  up  of  bacteria  or  tumor  cells  lodge  in  the  vessels  of  the 
body  and  are  destroyed  without  producing  any  discoverable 
lesion.  If  they  lodge,  however,  at  a  point  already  weakened  by  a 
pathologic  or  traumatic  process,  they  may  develop  and  cause  a 
much  more  serious  condition  than  the  primary  one  from  which 
they  arose.  As  an  illustration  of  this  statement  take  the  de- 
velopment of  tuberculous  processes,  most  of  which  are  doubtless 
of  secondary,  hematogenous  origin,  hi  a  bone  or  other*tissue  pre- 
vii  uisly  reduced  in  vitality.  So,  too,  emboli  from  malignant  tumors 
doubtless  frequently  lodge,  lose  their  vitality,  and  are  absorbed 
without  the  production  of  metastases.  This  doubtless  explains 
the  peculiar  distribution  of  such  metastases  hi  certain  cases  of 
malignancy.  As  in  cases  of  septic  emboli,  so,  too,  those  originating 
from  malignant  tumors  may  produce  a  condition  of  much  graver 
symptomatic  and  prognostic  importance  to  the  patient  than  the 
primary  lesion,  often  even  when  the  primary  lesion  itself  was  not 
known  to  exist. 

Points  of  Lodgment. — It  may  be  taken  as  a  broad  statement 
that  emboli  lodge  at  some  points  beyond  their  entrance  into  the 
vessels  and  are  carried  to  those  points  by,  and  in  the  direction  of, 
the  circulating  blood.  Occasionally  they  may  be  carried  for  a  part 
of  their  course  by  the  lymph-stream,  but  even  thus  they  are  de- 
posited in  the  general  circulation  unless  interrupted  by  a  lymph- 
node  or  by  lodgment  in  a  lymph-vessel  producing  lymphatic 
eml>oli-in.  Rarely,  however,  retrograde  emboli  are  observed, 
in  which  the  em  bolus  travels  against  the  current  of  the  blood  and 
Indues  at  a  point  in  the  vein  further  removed  from  the  heart  than 
the  point  of  origin.  By  virtue  of  the  structure  of  the  circulatory 
apparatus  one  would  naturally  conclude  that  emboli  originating 
from  the  veins  would  necessarily  hxlge  either  in  the  portal  dis- 
trilmtion  of  the  liver  or  in  the  capillaries  of  the  lung.  There  are 
a  few  exceptions  to  this  rule,  and  they  pass  under  the  name  of 
ixirn.ln.ric  or  crossed  emboli.  which,  though  unmistakably  form- 
ing in  the  veins,  are  lodged  in  the  capillaries  from  the  arterial  >i<le 
and  are  of  such  size  a>  to  render  their  passage  through  the  pul- 
monary capillaries  iinpn>-il»le.  They  pass  from  the  right  auricle 
through  the  foramen  ovale  into  the  left  auricle,  thence  into  the 
arterial  circulation.  The  possibility  of  thU  occurrence  is  all  the 
more  impressed  when  one  considers  that  this  foramen  is  imper- 


406  PRINCIPLES   OF   SURGERY 

fectly  closed  in  fully  80  per  cent,  of  cases.  Emboli  which  originate 
in  an  artery  or  which  are  deposited  in  an  artery  lodge  either  in 
the  branches  of  the  vessel  or  at  a  point  of  bifurcation.  Those 
arising  in  the  veins  lodge  in  the  first  group  of  capillaries  too  small 
to  let  them  pass,  namely,  either  in  the  liver  or  in  the  pulmonary 
artery  or  sometimes  in  the  right  heart,  if  they  are  very  large. 
Small  infected  emboli  tend  to  lodge  at  points  where  the  circula- 
tion is  slowest  or  where  the  resistance  of  the  tissue  is  most  re- 
duced, except,  of  course,  when  they  reach  vessels  through  which 
they  cannot  pass.  Owing  to  gravitation  influencing  certain  emboli 
there  seems  to  be  a  tendency  for  them  to  enter  the  lower  branches 
of  a  vessel  rather  than  the  higher  ones,  according  to  the  position 
occupied  by  the  patient  at  the  time.  The  vessels  most  frequently 
affected  by  emboli,  in  their  order,  are:  pulmonary,  renal,  splenic, 
cerebral,  iliac;  and,  while  others  are  affected  far  less  frequently, 
there  is  probably  no  vessel  in  the  body  secure  against  the  pos- 
sibility of  embolism.  The  condition  of  the  artery  may  serve  to  de- 
termine the  particular  point  at  which  the  embolus  lodges. 

Symptoms  of  Embolism. — The  symptoms  of  embolism,  like 
those  of  thrombosis,  are  very  variable,  and  they  vary  for  the 
same  reason  already  mentioned  under  that  heading.  If  an  em- 
bolus  lodges  in  a  large  artery  of  an  extremity  pain  is  almost  in- 
variably felt.  It  is  sudden  and  severe,  and  frequently  is  de- 
scribed by  the  patient  as  producing  the  sensation  of  a  blow.  In 
the  internal  vessels  pain  may  or  may  not  attend  upon  the  lodg- 
ment of  emboli,  and,  when  the  vessel  affected  is  a  small  and  unim- 
portant one,  will  probably  produce  either  no  symptoms  what- 
ever, or  symptoms  of  such  an  obscure  nature  that  diagnosis  is 
impossible.  If  an  embolus  lodges  in  an  important  internal  vessel 
it  may  produce  sudden  death,  as  it  frequently  does,  or,  failing 
this,  severe  and  permanent  crippling  of  the  structures  which 
receive  their  blood-supply  through  the  blocked  vessel.  If  an  em- 
bolus  lodges  in  an  important  structure,  but  cuts  off  the  blood- 
supply  from  only  a  small  portion  of  it,  or  if  it  lodges  in  the  brain, 
in  what  are  known  as  the  "silent  areas,"  no  evidence  of  such  an 
occurrence  is  likely  to  be  present.  The  temperature  in  cases  of  em- 
bolism may  remain  normal,  or  even  in  the  bland  variety  may  be 
raised  somewhat  above  normal,  while  in  the  septic  types  there  will 
appear  such  symptoms  in  a  few  hours  or  a  few  days  as  one  might 
expect  from  an  extension  of  an  infectious  process. 

In  surgical  work  there  are  certain  special  forms  of  emboli  which 
concern  us  particularly.  They  are:  thrombotic  emboli,  emboli  de- 
rived from  tumors,  bacteria  from  foci  of  infection,  fat  and  marrow 
emboli,  medicinal  emboli,  especially  oils,  mercury,  and  paraffin. 
It  is  necessary  to  call  especial  attention  to  certain  features  con- 


THROMBOSIS    AND    EMBOLISM  407 

• 

nected  with  each  of  these  types  of  embolism,  with  a  view  particu- 
larly to  their  prevention. 

In  all  cases  of  thrombosis  where  the  thrombus  is  of  such  an 
extent  as  to  deserve  the  name  it  is  necessary  to  follow  out  the 
rules  already  laid  down  under  the  subject  of  thrombosis,  with  a 
view  to  preventing  embolism.  It  may  be  wise  to  repeat  that  ex- 
<T< -i-e,  however  slight,  on  the  part  of  the  patient,  manipulation, 
ami  massage  are  absolutely  contra-indicated,  and  that  the  patient 
should  by  no  means  be  allowed  to  arise  from  his  bed  until  a  suffi- 
cient time  has  elapsed  to  permit  fixation  of  the  thrombus  in  situ. 
Especial  effort  should  be  made  to  prevent  infection. 

In  all  cases  where  malignant  tumors  are  known  to  be  present, 
and  in  all  tumors  suspected  of  malignancy,  it  should  be  the  ami  of 
the  physician  to  have  the  tumor  removed  at  as  early  a  date  as 
possible,  so  that  no  emboli  may  escape  from  the  tumor  and  lodge 
at  remote  points,  thus  rendering  the  prognosis  hopeless.  In  con- 
ducting their  examination  physicians  often  make  undue  and  un- 
sary  pressure  upon  malignant  tumors,  or  aspirate  them  with 
trochar  and  canula,  or  make  incisions  directly  into  the  tumor  for 
the  purpose  of  procuring  specimens  for  microscopic  examination; 
it  should  be  impressed  that  any  one  of  these  procedures  is  capable 
of  dislodging  fragments  of  the  tumor,  which  may  render  hopeless 
a  case  which  before  coming  to  the  physician  was  capable  of  cure. 
Patient-  themselves  have  a  habit  of  examining  their  own  tumors, 
if  accessible,  and  should  be  instructed  to  avoid  not  only  such  prac- 
tire.  but  all  possibilities  of  injury. 

The  same  rules  obtain  in  cases  of  localized  infection,  and  all 
trau mat  ism  and  rough  handling  of  the  infected  tissues  should  be 
looked  upon  as  of  no  service  hi  the  cure  of  the  condition,  and  at  the 
same  time  likely  to  cause  the  escape  of  infective  masses  into  the 
circulation  or  lymphatics.  In  fractures,  particularly  of  the  long 
hones,  undue  manipulation  will  only  increase  the  amount  of  fat 
that  ex-apes  into  the  general  circulation  (lipemia),  and  after 
sufficient  evidence  is  obtained  to  make  a  satisfactory  diagnosis 
should  by  no  means  be  indulged  in.  In  cases  of  lipemia  the  fat 
may  escape  with  the  urine,  but  the  quantity  of  it  is  less  hi  the 
urint-  \vhen  it  is  great  in  the  blood,  and  vice  versa.  It  rarely  shows 
up  in  the  urint  until  ahout  twelve  hours  after  the  receipt  of  the 
fracture,  and  more  commonly  not  until  the  expiration  of  three 
•  lay-. 

Air  emholi.  a>  ha-  already  heen  said,  result  from  the  entrance  of 
air  into  the  venous  circulation.  The  quantity  usually  received 
into  the  vessel  must  be  lurge  in  order  to  produce  severe  symptoms, 
hut  very  small  quantities  have  Keen  known  to  terminate  fatally. 
When  a  vessel  in  the  neck  has  heen  injured,  as  they  occasionally 


408  PRINCIPLES   OF   SURGERY 

are  even  by  the  best  of  surgeons,  owing  to  the  disturbance  of  the 
anatomic  relationship  by  the  pathology  present,  air  rushes  into 
the  open  mouth  of  the  vein  with  a  hissing,  lapping  sound.  Various 
explanations  have  been  advanced  as  to  how  air  embolism  produces 
death,  the  most  probable  one  of  which  is  that  the  air  and  blood 
become  whipped  into  a  froth  in  the  right  heart,  and  thus  inter- 
fere with  the  distribution  of  the  venous  blood  through  the  lungs. 
When  such  an  accident  happens  the  vessel  through  which  the  air  is 
entering  should  be  compressed  at  once,  so  as  to  prevent  further 
entrance  of  air.  Sudden  death  frequently  comes  as  a  result  of  such 
an  accident,  but  it  is  by  no  means  universal.  It  is  better  in  all 
cases  of  the  kind  to  locate  the  vessel,  if  possible,  and  cut  it  between 
double  ligatures  or  double  clamps,  so  that  no  air  may  enter. 

In  the  administration  of  oily  preparations,  such  as  mercury 
emulsified  hi  an  oil,  hi  the  treatment  of  syphilis,  or  of  paraffin  for 
cosmetic  purposes,  the  needle  should  be  filled  and  inserted  home, 
and  a  few  seconds  allowed  to  pass  while  the  syringe  is  disconnected 
from  the  needle.  If  the  needle,  then,  is  hi  a  vein,  blood  will  be 
found  either  to  escape  from  the  needle  or  to  force  the  oil  out  at  the 
open  extremity.  In  either  instance  the  point  of  the  needle  should 
be  shifted  so  as  to  avoid  the  possibility  of  embolism,  which,  while 
it  rarely  produces  death,  often  results  hi  very  distressing  and 
alarming  symptoms. 

Favorite  Sites  of  Lodgment. — From  what  has  been  previously 
said,  emboli  may  lodge  hi  any  of  the  vessels  into  which  they  may  be 
brought  by  the  blood-current;  certain  vessels  are  affected  appar- 
ently with  far  greater  frequency,  and  when  affected  produce 
symptoms  not  only  very  apparent,  but  very  alarming. 

When  an  embolus  lodges  in  one  of  the  coronary  arteries  of  the 
heart  sudden  death  usually  occurs.  But  it  is  not  constant.  When 
the  patient  survives  such  an  accident,  either  fatty  degeneration  of 
the  affected  muscular  area  or  infarction  takes  place.  The  symp- 
toms of  embolism  of  the  coronary  arteries,  if  not  fatal,  are  usually 
marked  and  alarming;  however,  there  may  be  no  symptoms.  They 
are  cardiac  asthma,  precordial  pain,  a  feeling  of  anxiety,  dysp- 
nea, a  sense  of  oppression,  or  angina.  The  heart  action  is  feeble 
and  likely  to  be  attended  with  arythmia  or  tachycardia.  Death 
usually  follows  such  an  attack  in  a  day  or  two,  but  is  not  constant. 
The  degenerative  changes  consequent  upon  impaired  nutrition  to 
the  heart  produces  a  gradually  increasing  weakness  of  that  organ. 

Embolism  of  the  large  arteries  of  the  extremities  cannot  be 
distinguished  from  thrombosis  except  by  the  suddenness  of  the 
onset,  and  this  is  not  an  altogether  reliable  differential  symptom, 
for  thrombosis  may  produce  a  sudden  onset.  The  history  of  the 
case,  and  the  knowledge  that  certain  conditions  exist  in  the  body 


THROMBOSIS    AND    EMBOLISM  409 

which  might  lead  to  one  or  the  other  of  these  conditions,  will  be 
extremely  helpful  in  differentiation. 

Embolism  of  the  arteries  of  the  kidneys  may  be  latent.  On 
the  other  hand,  it  may  be  attended  with  sudden  and  violent 
symptoms,  accompanied  by  confirmatory  changes  in  the  urine. 
After  a  major  operation,  following  thrombosis  of  any  type  or  as  a 
consequence  of  any  condition  capable  of  producing  embolism, 
sudden  pain  may  appear  in  the  dorsolumbar  region,  and  the 
urine  subsequently  secreted  may  show  blood  and  albumin.  This 
could  scarcely  be  interpreted  incorrectly,  but  less  typic  cases 
doubtless  often  escape  recognition. 

The  most  common  type  of  the  condition  is  that  affecting  the 
pulmonary  veins.  The  symptoms  here,  too,  are  not  constant,  and 
vary  all  the  way  from  a  transient  or  unrecognized  disturbance  to 
sudden  death.  In  the  latter  instance  the  patient,  without  warn- 
ing, suddenly  cries  out,  catches  at  the  precordial  region  on  account 
of  agonizing  pain,  becomes  pale,  pulseless  and  unable  to  breathe, 
and  dies  instantly.  If  death  does  not  occur,  the  pallor,  anguish 
in  the  heart  region,  oppression  and  dyspnea,  attended  with  few 
or  no  physical  signs  at  the  outset,  should  lead  to  a  correct  diag- 
nosis. Later  the  pallor  gives  way  to  cyanosis,  the  patient  be- 
comes anxious  and  restless,  and  physical  signs,  dependent,  of  course, 
on  the  volume  of  lung  involved,  appear.  They  are  not  of  constant 
type,  but  moist  rales,  impaired  breathing,  and  resonance  are  the 
signs  more  commonly  found,  usually  in  a  lower  lobe;  the  patient 
expectorates  abundant  frothy  sputum  which  may  be  blood- 
stained. The  blood-pressure  is  low  and  the  heart  rapid  and  often 
irregular.  Cough  is  usually  absent,  respiration  is  increased  in 
rate,  often  rapid,  and  deep  inspiration  gives  no  relief  to  the  in- 
tense air  hunger. 

Embolism  of  the  cerebral  vessels  is  identical  in  symptomatology 
with  thrombosis,  but  it  is  not  attended  with  prodromal  warnings. 
Sudden  death  may  occur,  or  paralysis  of  certain  groups  of  muscles 
is  soon  produced  here,  as  in  other  conditions,  which  impair  or 
tic-troy  the  function  of  brain  centers. 

Prognosis  of  Embolism. — Naturally,  the  prognosis  of  embolism 
is  us  varied  a>  the  importance  of  the  various  vessels  subject  to  It. 
Doubtless  many  emholi  lodge  without  the  slightest  subjective  or 
objective  evidence;  hut  when  emholi  lodge  in  the  more  important 
vessels  the  outlook  for  life  and  limb  is  very  often  grave,  even 
when  instant  death  is  escaped.  Embolism,  from  a  surgical  stand- 
point, is  of  the  greatest  intere-t.  as  it  is  chief  of  the  few  conditions 
capable  of  wiping  out  a  technical  masterpiece  in  the  twinkling  of 
an  eye,  and  stands  always  a  menace,  however  slight,  against  an 
otherwise  perfectly  safe  major  operation. 


410  PRINCIPLES   OF   SURGERY 

The  prognosis  of  emboli  which  contain  or  are  made  up  of  septic 
bacteria  is  altogether  bad;  it  is  the  beginning  of  septicemia  or 
pyemia,  and,  though  the  emboli  may  be  too  small  or  lodged  in 
vessels  too  unimportant  to  produce  symptoms  of  embolism,  the 
result  of  such  distribution  of  sepsis  is  exceedingly  grave. 

The  entrance  of  air  into  the  vessels  in  small  quantity  usually 
produces  no  harm;  there  are,  however,  exceptions  to  the  rule,  and 
even  small  quantities  of  air  should  be  excluded  from  medicaments 
which  must  or  may  enter  the  blood-vessels.  Large  quantities 
of  air  are  often  fatal;  this  is  thought  to  be  due  chiefly  to  the 
air  and  blood  being  whipped  into  a  froth  in  the  right  heart. 

Treatment. — The  treatment  of  embolism  is  divisible  into  pre- 
ventive and  curative. 

Preventive  Treatment. — Every  precaution  should  be  observed 
to  prevent  embolism,  and  this  should  be  especially  impressed  in 
certain  lesions  and  in  certain  surgical  procedures.  The  plan  for 
prevention  of  embolism  in  cases  of  thrombosis  has  already  been 
given.  In  cases  of  fracture  all  unnecessary  manipulation  must  be 
avoided,  and  if  it  is  necessary  to  move  the  patient  a  considerable 
distance  it  should  be  permitted  only  after  satisfactory  immobiliza- 
tion. In  operations  on  fat  individuals  the  dissections  should  be 
made  with  knife  and  scissors,  never  by  tearing  and  bruising  the 
structures.  Doubtless  a  certain  amount  of  fat  enters  the  vessels 
in  all  such  cases,  but  it  should  be  held  at  a  minimum.  In  opera- 
tions on  the  neck  and  upper  thorax  continued  watchfulness  must 
be  exerted  for  severed  veins — they  should  be,  if  possible,  clamped 
or  ligated  before  incision.  If  air  is  heard  to  enter  such  a  vein,  it 
should  be  blocked  at  once  and  caught  up,  preferably  during  ex- 
piration. All  hypodermic,  intramuscular,  and  intravascular  in- 
jections should  be  guarded  against  carrying  air  into  the  tissues. 
I  have  seen  air  forced  into  a  vein  during  intravenous  saline  injec- 
tion due  to  the  intern  mistaking  the  level  of  water  outside  the 
bottle  for  the  level  within.  All  oily  substances,  all  substances, 
indeed,  which  are  insoluble  in  the  blood  should  be  injected  through 
a  needle  large  enough  to  allow  the  escape  of  blood  during  the  few 
seconds  the  syringe  is  disconnected  from  the  needle  after  insertion 
of  the  latter,  and  disconnection  should  never  fail  to  be  made. 

Active  Treatment. — There  is  little  to  do  in  the  ordinary  case  of 
embolism  except  to  meet  the  physiologic  requirements  as  well  as 
possible.  Rest  in  the  recumbent  position,  control  of  pain  with 
opiates,  moderate  stimulation  of  the  heart,  and  administration  of 
oxygen  by  inhalation,  if  disturbance  of  respiration  demands  it, 
cover  the  routine  of  general  treatment.  To  this  it  must  be  added 
that  whatever  local  demands  arise  are  to  be  met  pro  re  nata. 

In  cases  of  air  embolism  it  has  recently  been  suggested  that, 


THROMBOSIS    AND    EMBOLISM  411 

owing  to  the  interference  of  the  froth  in  the  right  heart  with  the 
circulation,  the  indications  are  best  met  by  injecting  300  c.c.  of 
normal  saline  solution  containing  20  to  30  min.  of  adrenalin  chlorid, 
1 : 1000,  directly  into  the  right  heart  through  the  open  vein  in  the 
neck. 

Embolism  of  a  large  vessel  of  an  extremity  should  be  treated 
at  once  by  incising  the  artery,  removal  of  the  embolus,  and  arterial 
-mure. 


CHAPTER    XXVIII 
ANEURYSM 

ANEURYSM  is  a  cavity  or  sac  filled  with  blood  and  communicat- 
ing with  the  lumen  of  an  artery.  The  limiting  wall  may  consist  of 
one  or  more  arterial  coats,  of  normal  tissues,  or  of  new-formed 
fibrous  tissue.  Ordinarily  aneurysm  may  be  defined  as  an  abnor- 
mal permanent  dilatation  of  an  artery,  but  the  definition  above  is 
made  more  comprehensive  to  cover  arteriovenous  aneurysms  and 
diffuse  aneurysms. 

Types.  —  Aneurysms  are  classed  as  true  or  false.  A  true  aneu- 
rysm is  one  whose  sac  consists  of  the  coats  of  the  artery.  The 
term  is  widely  used  to  signify  that  the  sac  must  be  made  up  of  all 
three  coats,  but  such  a  classification  has  only  caused  confusion. 
A  false,  or  spurious,  aneurysm  is  one  whose  limiting  walls  are  not 
made  up  of  vascular  coats,  but  of  normal  or  adventitious  structures. 
The  false  aneurysms  may  be  circumscribed,  where  an  artificial 
sac  has  developed,  or  diffuse,  in  which  the  blood  is  limited  only  by 
the  anatomic  spaces  into  which  it  has  escaped.  It  is  little  more 
than  arterial  hematoma.  It  is  of  no  practical  value  to  distinguish 
between  an  aneurysm  whose  sac  is  made  up  of  all  the  arterial  coats 
and  one  whose  sac  is  made  up  of  one  or  two  of  them;  but  it  is  im- 
portant to  distinguish  one  whose  sac  is  made  up  of  vascular  coats 
from  one  whose  sac  is  not. 

The  classification  may  be  given,  then,  as  follows: 

f  1.  Cylindric. 

|  2.  Sacculated  or  sacciform. 


True  aneurysms  <     ;  coidr  plexiform,  angioma 

l5.Arteriovenous{S 
False  aneurysms  {g~cribed- 

A  cylindric  aneurysm  is  produced  by  a  uniform  dilatation  of 
the  artery,  and  assumes  a  spindle  shape  usually  rather  than  the 
cylindric. 

Sacculated  aneurysm  is  due  to  a  dilatation  of  the  arterial  coats 
from  one  side,  the  remainder  of  the  circumference  of  the  artery 
remaining  more  or  less  undisturbed.  The  opening  from  the  lumen 
of  the  artery  into  the  sac  may  be  small  as  compared  with  the  size 
of  the  sac. 

412 


ANEURYSM 


413 


Dissecting  aneurysm  is  due  to  the  escape  of  blood  through 
some  of  the  arterial  coats  and  the  forcible  separation  of  these 
coats  from  each  other.  The  plane  of  separation  may  be  between 
ultima  and  media,  within  the  substance  of  the  media,  or  between 
media  and  adventitia.  There  may  be  a  single  opening  or  there 
may  be  two,  so  that  the  blood  may  circulate  from  the  vessel 
through  one  and  into  it  again  through  the  other.  According  to  the 


Fig.  82. — Dissecting  aneurysm  of  the  aortic  arch. 

usual  classification  into  true  and  false  aneurysms  this  constitutes  an 
intermediate  step  (Kaufnuinn). 

Cirsoid  aneurv-m  is  sometimes  classed  as  an  aneurysm  and 
again  as  a  tumor.  As  a  matter  of  fact,  it  belongs  to  neither;  it  is  a 
form  of  telangieetasis.  It  will  ho  discussed  further  under  the  cap- 
tion of  Vascular  Tumors.  It  is  a  dilated,  elongated,  tortuous 
artery  or  group  of  arterie*.  and  tends  to  affect  certain  regions, 
e-pecially  the  anterior  branch  of  the  temporal. 


414  PRINCIPLES   OF   SURGERY 

An  arteriovenous  aneurysm  is  one  produced  by  the  com- 
munication of  an  artery  with  a  vein.  There  are  two  types — vari- 
cose aneurysm,  in  which  communication  is  not  direct,  there  being 
an  intervening  sac,  and  aneurysmal  varix,  in  which  the  com- 
munication is  direct.  In  varicose  aneurysm  the  sac  and  the  vein 
at  the  point  of  communication  are  both  dilated,  and  in  aneurysmal 
varix  the  vein  is  dilated  at  the  point  of  communication.  In  both 
the  vein  pulsates  at  its  dilated  portion. 

The  circumscribed  false  aneurysm  is  one  in  which  the  blood 
escaping  from  the  artery  is  confined  to  that  region  by  surround- 
ing connective  tissue  in  the  form  of  a  bag  or  sac.  The  diffuse 
aneurysm  is  not  limited  to  any  definite  form,  and  the  blood  may 
dissect  its  way  among  the  anatomic  structures  as  far  as  the  blood- 
pressure  and  the  particular  location  of  the  aneurysm  may  require. 

Etiology. — The  causation  of  aneurysm  is  due  to  one  of  two 
conditions,  or  to  a  combination  of  these  two  factors,  namely,  an 
increase  in  the  blood-pressure  or  a  reduction  in  the  strength  and 
elasticity  of  the  arterial  coats.  Hence,  when  the  arteries  are  dam- 
aged the  usual  pressure  of  the  blood  may  be  sufficient  to  cause 
aneurysm,  .and  this  is  all  the  more  likely  to  happen  if  from  physio- 
logic, pathologic,  or  therapeutic  causes  the  blood-pressure  is  in- 
creased. 

The  conditions  favoring  a  high  tension  of  the  arteries  are  ex- 
cessive eating,  especially  of  nitrogenous  food,  exercise,  especially  if 
violent,  such  as  is  engaged  in  in  athletics,  running,  rowing,  boxing, 
wrestling  and  foot-ball,  and  anger  or  excitement.  Pathologic  con- 
ditions which  favor  it  are  general  arteriosclerosis,  nephritis, 
uremic  and  eclamptic  conditions,  angina  pectoris,  and  convulsions; 
the  latter  raise  the  blood-pressure  by  virtue  of  the  muscular  ex- 
ercise incurred.  The  therapeutic  agents  raising  the  blood-pressure 
include  all  drugs  which  stimulate  the  heart  and  constrict  the 
arteries,  chief  among  them  being  adrenalin,  strychnin,  and  digi- 
talis or  its  derivatives. 

The  changes  in  the  arterial  coats  which  favor  loss  of  elasticity 
and  resistance  include,  first  of  all,  traumatism,  which,  by  destroy- 
ing one  or  more  of  the  arterial  coats,  and  often  in  addition  related 
anatomic  structures  which  offer  additional  support,  may  be  the 
direct  and  sole  cause  of  aneurysm  in  individuals  whose  blood- 
pressure  is  normal  or  below  normal.  The  nature  of  the  trauma  is 
immaterial.  It  may  be  produced  by  blows,  cuts,  gunshot,  or  even 
by  so  slight  an  injury  as  the  passage  of  a  needle  through  the 
vascular  walls.  It  is  the  establishment  of  a  traumatic  severance 
of  the  coats  that  counts.  Second,  must  be  included  all  those 
pathologic  changes  that  may  result  in  sclerosis  or  atheromatous 
degeneration,  and  it  may  be  stated  here  that  a  priori  aneurysms 


ANEURYSM  415 

would  be  most  common  at  those  points  in  the  arterial  system 
where  these  changes  are  most  frequent  and  intense.  Since  these 
arterial  changes  are  a  concomitant  of  old  age,  senility  is  given  as 
one  of  the  predisposing  causes  of  aneurysm.  Syphilis  is  another 
cause  of  atheroma  and  sclerosis  of  extremely  common  occurrence, 
and  is  the  chief  cause  of  early  hardening  of  the  arteries.  Chronic 
interstitial  nephritis,  gout,  diabetes,  and  obesity  are  accepted 
as  causative  factors,  and  excessive  use  of  tea,  coffee,  and  tobacco 
have  been  held  as  causes. 

Once  the  walls  are  crippled  the  predisposing  factor  is  es- 
tablished, and  only  a  sufficient  blood-pressure  is  needed  now, 
as  an  exciting  cause,  to  establish  aneurysm. 

In  arteriovenous  aneurysm  the  communication  between  the 
two  vessels  is  established  as  a  consequence  of  trauma — a  bullet, 


Fiji.  SJi. — Aneurysm  of  the  first  division  of  the  aortic  arch. 

knife,  or  needle  penetrating  both  vessels  at  once  and  short-cir- 
cuit in.u  the  blood-stream  through  the  opening. 

Pathology. — An  aneurysm  consists  of  the  sac  and  its  contents. 
The  nature  of  the  sac  is  sufficiently  understood  from  what  has 
lieen  said  already.  The  contents  are  either  fluid  blood,  clotted 
blood,  or  the  organized  or  semi-organized  remains  of  blood-clots. 
A-  the  l»loo<l  circulates  in  the  peripheral  zone  of  the  sac  its  rate  of 
motion  is  slowed,  and.  often  favored  by  the  condition  of  the  lining 
of  the  sac,  coagulates,  forming  a  clot  lying  concentric  with  the  sac. 
Tin-  produces  a  red  clot,  which  as  it  grow-  older  becomes  paler, 
adheres  to  the  wall,  and  begins  to  be  converted  into  cicatricial 
ti-sue.  Meantime  a  -econd  clot  may  form  on  the  internal  surface 
of  the  fir>t.  and  the  size  of  the  aneurysmal  sac  may  be  still  further 


416  PRINCIPLES   OF   SURGERY 

increased  by  continued  dilatation  of  the  sac;  so  the  clot  forms  in 
layers  which  are  concentric,  the  outermost  being  the  oldest,  the 
palest,  and  the  most  completely  organized. 

Signs  and  Symptoms  of  Aneurysms. — The  most  prominent 
sign  of  an  aneurysm,  and  the  sign  most  universally  accepted  as 
diagnostic  of  the  condition,  is  that  it  is  a  pulsating  tumor  lying 
in  the  course  of  an  artery,  usually  one  of  the  more  important 
arteries.  The  pulsation  is  synchronous  with  the  heart-beats  and 


Fig.  84. — Aneurysm  of  the  aortic  arch  in  a  syphilitic  thirty-one  years  old. 
Several  ribs  are  completely  absorbed. 

of  the  same  rate.  Pressure  on  the  artery  supplying  an  aneurysm — 
i.  e.,  proximal  to  it — stops  pulsation  in  it,  and  it  becomes  smaller 
as  the  blood  it  contains  is  forced  out  by  the  elastic  contraction  of 
its  sac.  Pressure  on  the  artery  leading  from  an  aneurysm — i.  e., 
distal  to  it — increases  the  size  and  tension  of  the  sac.  By  steady, 
uniform  pressure  on  the  aneurysm  itself  the  size  of  the  tumor  may 
be  reduced,  but  only  to  the  extent  of  its  content  of  fluid  blood. 
The  pulse  distal  to  an  aneurysm  may  be  slightly  retarded,  so  that 
a  comparison  of  the  two  sides  of  the  body  shows  the  pulse  on  the 


ANEURYSM 


417 


diseased  side  striking  a  little  after  that  of  the  other  is  felt.  The 
pulsation  of  an  aneurysm  is  centrifugal  hi  direction,  the  reason 
for  which  is  readily  explained  on  physical  grounds,  and  entirely 
unlike  the  pulsation  transmitted  to  a  tumor  or  an  abscess  overly- 
ing an  artery;  hi  the  latter  instance  there  is  no  expansile,  centrif- 
ugal effect,  but  only  a  lifting  of  the  mass  away  from  the  artery. 
Hence,  if  such  a  tumor  be  palpated  by  the  two  hands,  one  on  either 
side  of  it,  they  are  not  separated  during  pulsation,  whereas  in 
aneury-ms  they  are  separated. 

On  palpation  the  surface  of  an  aneurysm  is  smooth  and  even 
and,  it  may  be,  fluctuant,  unless  the  sac  be  filled  with  clots.    The 


Fig.  85. — Aneurysm  of  right  common  carotid. 

size  varies,  but  in  the  largest  vessels  it  may. reach  the  size  of  a 
child's  head.    They  are  rarely  larger  than  an  orange. 

By  li- tming  to  an  aneurysm  one  may  hear  the  aneurysmal 
bruit,  a  purring  sound  produced  by  the  passage  of  blood  through 
the  cavity.  It  is  almost  constant,  and  when  distinctly  heard  can 
l>e  mi-taken  for  no  other  sound.  The  only  trouble  is  that  it  is  most 
iliflicult  to  recognize  in  precisely  those  cases  where  its  detection 
would  render  the  greatest  -ervire.  namely,  in  deep  aneurysms,  as 
of  the  thorax  or  abdomen.  The  bruit  of  an  aneurysm  is  more 
clo-ely  imitated  \>y  the  uterine  soulile  of  pregnancy  than  by  any 
other  normal  sound.  It  is  also  simulated  sometimes  when  an 
artery  ha>  Keen  partially  oh-trucled,  as  may  occasionally  be 


418  PRINCIPLES   OF   SURGERY 

heard  in  the  neck  hi  cases  of  empyema.  Palpation  may  reveal  a 
more  or  less  distinct  thrill. 

Aneurysms  may  exist  indefinitely  without  the  causation  of 
symptoms,  or  they  may  produce,  by  virtue  of  their  location,  such 
obscure  symptoms  that  they  are  of  no  value  to  the  clinician  and 
no  diagnosis  can  be  determined  until  postmortem.  One  of  the 
frequent  symptoms  of  aneurysm  is  pain.  This  may  occur  inde- 
pendently of  the  location  of  the  mass,  but  is  more  severe  and  more 
common  when  the  aneurysm  is  situated  hi  such  a  position  that  it 
may  press  upon  important  nerves.  Marked  interference  with  the 
return  circulation  may  develop  as  a  result  of  pressure  of  the 
aneurysm  on  the  veins  hi  relation  with  it.  This  may  result  in 
edema,  thrombosis,  and  the  whole  train  of  lesions  following  in  the 
wake  of  severe  passive  hyperemia. 

By  its  pressure  upon  surrounding  structures  destruction  or 
crippling  may  occur  to  such  degree  that  the  damage  done  thereby 
causes  more  alarm  than  the  aneurysm  itself.  Thus,  an  aneurysm 
of  the  arch  of  the  aorta  may  cause  paralysis  of  the  recurrent 
laryngeal  nerve  and  consequent  aphonia;  or,  by  pressure  on  the 
anterior  bony  wall  of  the  chest,  cause  its  entire  disappearance  by 
absorption,  so  that  the  pulsations  may  be  both  seen  and  felt.  This 
absorption  advances  to  such  a  stage  that  the  aneurysm  may  rup- 
ture externally  and  in  an  instant  pour  out  all  of  the  patient's 
blood.  So,  too,  the  vertebrae  and  other  bones  may  also  be  ab- 
sorbed. 

The  mechanical  presence  of  a  large  aneurysm  is  capable  of 
producing  symptoms  referable  to  structures  whose  function  is 
independent  of  the  vascular  system,  just  as  a  tumor  or  cyst  simi- 
larly situated  might  do.  Moreover,  the  sensory  nerves  which  are 
pressed  upon  may  produce  various  paresthesias,  as  itching,  numb- 
ness, formication. 

Course. — The  usual  behavior  of  aneurysms  is  toward  a  bad 
end.  They  continue,  as  a  rule,  to  enlarge,  until  by  rupture,  pres- 
sure, or  complication  they  cause  the  death  of  the  patient.  Spon- 
taneous cure  is  a  rare  termination.  It  may  be  brought  about  by 
thrombosis  of  the  whole  cavity  of  the  sac,  by  the  escape  of  a  mass 
from  the  lining  thrombus,  which  plugs  the  main  outlet  and  pro- 
duces thrombosis  and  ultimately  a  cure.  When  rupture  occurs 
it  may  take  one  of  four  courses:  first,  into  an  adjacent  vein,  caus- 
ing secondary  arterio venous  aneurysm;  rupture  into  the  tissues, 
causing  either  a  diffuse  aneurysm  or  gangrene  of  the  part;  rupture 
into  an  important  serous  cavity,  with  sudden  pallor  and  death; 
rupture  externally  and  death  by  hemorrhage.  An  aneurj'sm  may 
rarely  become  infected  and  suffer  disintegration  of  its  sac  and  the 
contained  clots.  Gangrene  may  result  from  pressure  due  to  im- 


ANEURYSM  419 

pingement  of  the  mass  on  the  return  veins,  by  rupture  and  the 
escape  of  large  quantities  of  blood  into  the  tissues,  and  by  throm- 
bosis or  embolism  which  blocks  the  arterial  outlet. 

Treatment. — The  treatment  of  aneurysm  falls  under  two  head- 
ings— non-operative  and  operative.  It  is  but  just  to  say  at  the 
outset  that  the  treatment  should,  when  feasible,  be  operative,  as 
this  offers  much  better  results  when  it  can  be  done;  however, 
there  are  many  aneurysms  so  situated  as  to  be  so  far  not  amenable 
to  operative  treatment  and  many  conditions  which  contra-indicate 
surgical  interference.  Hence,  the  non-operative  treatment  must 
continue  to  be  employed. 

NON-OPERATIVE  TREATMENT. — It  is  the  purpose  of  all  non- 
operative  plans  of  treatment  to  reduce  the  rate  of  flow  of  the 
blood,  to  increase  its  coagulability,  or  to  combine  the  two. 
This  favors  the  formation  of  thrombi  in  the  sac,  and  produces  cure 
along  the  lines  indicated  by  observation  of  spontaneous  cures. 
The  results  are  accomplished  by  various  methods,  some  of  which 
are  antiquated  and  no  longer  employed. 

Tufnell's  plan  is  based  upon  the  fact  that  rest  reduces  the 
blood-pressure  and  the  number  of  heart-beats,  and  that  reduction 
of  the  quantity  of  fluid  and  diet  increases  the  coagulability  of  the 
blood.  These  observations  were  put  into  practice  by  Tufnell 
almost  to  the  limit  of  tolerance.  His  plan  allows  a  minimum  of 
food — 3  ounces  of  meat,  8  ounces  of  milk,  4  ounces  of  bread,  and  a 
small  quantity  of  butter  during  each  twenty-four  hours,  with  as 
great  restriction  of  fluids  as  possible;  the  patient  must  rest  in  bed 
without  rising,  and  be  free  from  mental  anxiety  and  worry. 
The  plan  must  be  followed  for  several  months  to  be  effective.  If 
necessary,  the  patient  may  take  a  rest  from  the  treatment  and 
return  to  a  moderate  diet  for  a  week  or  two,  and  then  return  to  the 
ali>temious  plan  outlined.  The  most  that  can  be  said  for  the  plan 
i>  that  it  has  occasionally  resulted  in  cures. 

Valsalva  recommended  venesection,  which  might  be  repeated 
from  time  to  time,  rest,  and  starvation  diet. .  It  is  practically  the 
same  as  Tufnell's  plan. 

These  plans  have  outlined  the  chief  features  of  the  rest  cure, 
Imt  it  will  rarely  be  possible  in  this  country  to  carry  the  measures 
to  the  extreme  recommenoVl. 

Lancereaux's  Plan. — Gelatin  injections  into  the  subcutaneous 
ti-sut  -  remote  from  the  aneurysm  have  been  used  because  of  the 
power  of  gelatin  to  increase  the  coagulability  of  the  blood.  Doses 
of  100  c.c.  or  more  of  a  5  to  10  per  cent,  solution  (Carnot's  solution) 
in  normal  salt  solution  are  used,  and  repeated  every  ten  to  fifteen 
•  lay-.  It  i>  a  dangerous  plan  of  treatment,  positively  contra- 
indicated  if  there  is  renal  disease,  and  has  occasionally  produced 


420  PRINCIPLES   OF   SURGERY 

tetanus.  Hence,  if  one  essays  its  use  the  most  rigid  sterilization 
is  enjoined.  It  is  of  questionable  value. 

The  pain  of  aneurysm  is  often  amenable  to  potassium  iodid 
given  in  moderate  doses  (20  to  40  gr.)  three  times  a  day.  It  seems 
to  serve  the  purpose  as  well  La  non-syphilitics  as  in  syphilitic 
cases. 

Cure  has  been  undertaken  by  forcible  manipulation  of  the 
sac,  with  a  view  to  breaking  up  the  clot  and  allowing  it  to  lodge 
at  the  outgoing  vessels.  For  manifest  reasons  the  plan  is  danger- 
ous and  should  not  be  employed. 

Pressure  by  various  devices  has  been  employed  upon  the 
artery  on  either  side  of  the  aneurysm  with  occasional  success. 
Manual  pressure  produced  by  several  individuals  working  in  relays, 
tourniquets,  weights,  compresses,  and  such  like  represent  the  va- 
riety of  devices  employed. 

Electricity  has  been  employed,  and  perhaps  the  most  satis- 
factory plan  for  its  use  is  by  the  electrolytic  action  of  needles 
introduced  into  the  cavity  of  the  sac.  It  is  unsatisfactory. 

Injection  of  astringent  and  coagulating  drugs  is  no  longer  em- 
ployed, but  the  old  plan  of  introducing  a  fine  wire  through  a  small 
hollow  needle  or  canula  inserted  obliquely  into  the  sac  has  been 
successful  often  enough  to  warrant  its  continuance,  and  shows 
some  splendid  results.  The  wire  should  be  very  fine,  incapable 
of  -corrosion,  sterile,  very  long,  and  wound  in  such  manner  before 
its  introduction  as  to  guarantee  that  it  will,  when  introduced, 
spread  itself  throughout  the  sac.  The  plan,  of  course,  is  not 
without  danger. 

OPERATIVE  PLANS. — The  operative  plans  may  be  subdivided 
into  three  groups:  First,  those  which  remove  or  destroy  the 
aneurysm  in  toto;  second,  those  which  leave  the  sac,  but  by  means 
of  ligature  shut  off  the  circulation  sufficiently  to  admit  of  coagula- 
tion; third,  those  which  essay  to  reconstruct  the  artery.  The  first 
plan  is  the  most  certain  of  cure  when  it  can  be  safely  employed; 
both  the  first  and  second  groups  presuppose  an  adequate  collateral 
circulation,  and  a  knowledge  of  anatomy  sufficient  to  warrant  that 
the  ligatures  will  "be  so  placed  as  to  avoid  destruction  of  the  vessels 
which  must  supply  blood  to  the  parts  distal  to  the  aneurysm. 
The  third  plan  is  ideal  when  the  location  of  the  aneurysm  and  the 
quality  of  the  vascular  wall  permit  its  employment. 

The  oldest  "method,  that  devised  and  employed  by  Pkilagrius, 
of  Macedonia,  gives  certain  relief  from  the  aneurysm  and  from 
the  danger  of  recurrence  or  complication.  It  consists  in  ligation, 
both  proximal  and  distal  to  the  sac,  and  complete  extirpation  of 
sac  and  contents. 

Antyllus'  method  was  to  ligate  the  artery,  both  proximal  and 


ANEURYSM  421 

distal  to  the  sac,  incise  the  sac,  and  clean  out  its  contents,  and  has 
in  it  the  possibility  of  relief  in  most  cases. 

Hunter's  method  consists  in  ligation  of  the  artery  on  the  prox- 
imal side  of  the  aneurysm  and  at  some  distance  from  it.  This 
is  especially  a  valuable  plan  where  the  aneurysm  is  associated  with 
severe  disease  of  the  arteries,  as  the  vessel  is  in  worse  condition 
near  the  aneurysm.  It  has  been  most  frequently  practised  in 
ligation  of  the  femoral  artery  at  the  apex  of  Scarpa's  triangle  in 
cases  of  popliteal  aneurysm. 

Anel's  method  is  to  ligate  the  artery  proximal  to  the  sac  and 
close  to  it.  A  little  reflection  will  show  that  this  plan,  while  not 
as  good  in  certain  instances  as  Hunter's  plan  on  account  of  the 
pathologic  changes  in  the  arterial  wall,  may  be  applied  in  many 
cases  where  Hunter's  could  not  be  used. 

Brasdor's  plan  is  the  ligation  of  the  vessel  close  to  the  aneu- 
rysmal  sac  on  the  distal  side. 

Wardrop's  plan  consists  in  the  ligation  of  one  or  more  of  the 
main  branches  of  the  artery  distal  to  the  sac.  For  example,  the 
external  carotid  may  be  ligated  in  case  of  a  large  aneurysm  situ- 
ated low  down  in  the  common  carotid. 

All  these  plans  are  to  be  employed  with  careful  application  of 
the  ligatures  at  such  points  that  they  will  not  cut  off  the  blood- 
supply  from  collaterals  which  must  nourish  the  structures  distal 
to  the  ligatures.  These,  it  must  be  remembered,  may  be  rendered 
ineffective,  either  by  an  unwise  location  of  the  ligature,  so  as  to 
place  the  collateral  vessels  all  on  one  side  of  the  point  of  ligation, 
or  by  the  use  of  unnecessarily  large  or  improperly  located  incisions, 
or  by  rough  handling  of  the  tissues  or  their  laceration  by  retractors. 

The  third  plan  seeks  neither  to  excise  the  aneurysm  as  a  whole, 
nor  to  interfere  with  the  structures  in  relation  with  the  sac;  it  also 
proposes  to  conserve  the  collateral  circulation  more  perfectly  than 
can  l>e  done  in  any  other  plan.  It  is  known  as  the  plan  of  Matas, 
its  inventor,  or,  as  he  calls  it,  endo-aneurysmorrhaphy,  and  it  is 
precisely  that  the  aneurysm  is  dealt  with  from  its  internal  rather 
than  its  external  surface  that,  in  Matas'  opinion,  gives  it  its  chief 
value.  The  difficulty  of  doing  the  operation  of  total  excision, 
manifestly  the  most  satisfactory  of  the  already  described  plans,  or 
the  double  libation  (Antylus),  and  incision  and  packing  of  the  sac, 
and  t  lie  fact  that  they  are  more  likely  to  be  followed  by  hemorrhage, 
infection,  or  gangrene  than  are  those  done  according  to  Matas' 
plan,  have  served  as  stimuli  to  its  adoption. 

Matas'  plan  embraces  those  methods  of  procedure  to  be 
determined  by  the  type  of  aneurysm  and  the  conditions  en- 
countered on  entering  and  cleaning  out  the  sac.  The  methods  are 
the  oMiterative.  the  restorative,  and  the  reconstructive. 


422  PRINCIPLES   OF   SURGERY 

Up  to  a  certain  point  the  procedure  is  the  same  in  all  three 
methods.  The  incision  is  made  down  to  the  sac;  the  vessel  is 
clamped  above  and  below  the  sac  sufficiently  only  to  control  the 
passage  of  blood  through  the  lumen.  The  sac  is  opened  from  one 
end  to  the  other  and  thoroughly  cleaned  out,  and  the  openings  of 
all  branches  leading  from  the  sac  are  sought  and  closed  by  suture. 
If  the  condition  found  is  such  as  to  preclude  the  possibility  of  suc- 
cess with  the  second  or  third,  or  if  the  aneurysm  be  distinctly  of 
the  fusiform  variety,  if  the  vessels  are  too  hard,  too  degenerated, 
and  inelastic  to  encourage  the  establishment  of  a  new  artery,  the 
first  plan  is  employed.  The  sides  of  the  sac  are  then  sutured  to 
each  other  firmly  from  one  end  to  the  other,  and  additional 
sutures  are  placed  in  tiers  till  the  whole  sac  is  obliterated.  The 
second  of  Matas'  procedures  is  the  restorative  method,  useful  in 
sacculated  aneurysms  which  communicate  with  the  artery  through 
a  slit-like  opening  through  the  side  of  the  vessel,  and  in  which  the 
original  shape  of  the  vessel  is  maintained  except  for  the  slit.  In 
this  instance  the  edges  of  the  slit  are  sutured  to  each  other  by 
continuous  or  interrupted  sutures  and  the  blood-stream  turned  on 
to  test  the  efficiency  of  the  sutures,  which  may  be  reinforced  at 
various  points  if  necessary.  The  sac  is  then  obliterated  by  suture, 
as  described  above.  This  reestablishes  the  artery,  and,  unless  a 
thrombus  should  form,  not  only  removes  the  aneurysm  and  its 
dangers,  but,  if  successful,  escapes  the  greatest  danger  of  the 
ligature  plans,  which  are  attended  by  gangrene  of  the  extremity  hi 
more  than  7  per  cent,  of  the  cases. 

The  reconstruction  plan  is  employed  in  cases  of  fusiform  aneu- 
rysms in  which  there  remains  no  part  of  the  original  arterial  wall 
in  an  intact  condition.  The  coats  of  the  sac  must  be  "firm,  elastic, 
and  resistant,  and  the  two  openings  leading  to  the  main  artery  lie 
on  the  same  level,  hi  close  proximity,  and  situated  at  the  bottom 
of  a  superficial  or  readily  accessible  sac."  After  clamping  the  arte- 
ries and  opening  and  cleaning  the  sac  a  rubber  tube  is  introduced 
into  the  lumina.  It  should  be  large  enough  barely  to  enter  the 
vessels.  After  introducing  the  tube,  the  sides  of  the  sac  are 
sutured  so  as  to  make  the  reconstructed  portion  equal  in  diameter 
to  that  above  and  below.  When  the  sutures  are  introduced  they 
are  left  untied  until  the  tube  is  removed.  The  same  steps  are 
followed  here  as  in  the  previous  procedures  to  test  the  closure, 
which,  if  unsatisfactory,  is  reinforced.  Then  the  sac  is  approxi- 
mated over  the  reconstructed  portion  by  additional  tiers  of  sutures. 

In  cases  where  obliterative  aneurysmorrhaphy  is  to  be  prac- 
tised in  an  extremity  it  is  wise  to  test  the  efficiency  of  the  col- 
lateral circulation  by  removing  all  blood  from  the  limb  by 
Esmarch's  plan  and  placing  special  clamps  on  the  vessel,  which 


ANEURYSM  423 

does  not  allow  the  circulating  blood  to  pass.  It  is  applied  tightly 
enough  when  pulsation  ceases  in  the  distal  branches.  The  reap- 
pearance of  the  capillary  circulation  in  and  the  maintenance  of 
the  warmth  of  the  skin  indicate  an  adequate  collateral  circula- 
tion; it  has  been  proved  in  actual  practice  that  such  a  return  in 
five  hours  was  sufficient.  Failure  of  such  return  of  the  circula- 
tion suggests  great  danger  of  gangrene  in  case  any  obliterative  or 
ligature  operation  is  done. 

The  possibility  of  increasing  the  efficiency  of  the  collateral 
circulation  by  repeated  prolonged  temporary  obstruction  of  the 
main  artery  for  a  considerable  period  prior  to  operation  increases 
tin  efficiency  of  the  collateral  circulation. 

Subsequent  to  any  operative  plan  certain  important  features 
must  be  religiously  enforced.  In  the  first  place,  the  dressings 
should  be  applied  loosely,  so  as  to  avoid  the  most  insignificant 
interference  with  the  circulation;  second,  the  part  should,  if  pos- 
sible, be  elevated  somewhat  to  encourage  easier  return  of  venous 
blood,  and,  third,  the  temperature  of  the  part  must  be  maintained 
artificially  if  the  circulation  is  inadequate. 

Arteriovenous  aneurysms  are  in  some  respects  much  less  amen- 
able to  treatment  than  the  usual  forms.  The  ideal  plan,  when 
practicable,  is  separation  of  the  artery  and  vein  and  closure  of  the 
rent  in  each  by  suture;  or  closure  of  the  vein  laterally  and  resection 
of  the  crippled  segment  of  the  artery  and  end-to-end  anastomosis. 
The  plans  of  ligation  of  the  artery  or  of  both  artery  and  vein  on 
cither  or  both  sides  of  the  aneurysm  are  often  unsatisfactory, 
and  if  both  vessels  are  important,  as  they  usually  are,  is  likely  to 
fail  or  to  produce  gangrene  in  a  considerable  percentage  of  the 
cases. 

Kxpectant  treatment  by  compression  over  the  aneurysm  or  over 
the  artery  proximal  to  the  aneurysm  is  justifiable  in  aneurysmal 
varices,  but  should  not  be  relied  on  in  varicose  aneurysms  where 
circumstances  will  admit  operative  measures. 

Cirsoid  aneurysms  are,  from  the  standpoint  of  treatment,  the 
most  formidable,  and  offer  the  least  hope  of  cure.  When  they  are  of 
limited  extent  they  are  best  treated  by  total  excision;  if  they  are 
very  large,  the  operation  may  be  done  at  several  sittings.  Liga- 
tion of  the  main  vessel  leading  to  the  aneurysm  is  rarely  success- 
ful; so  also  are  the  plans  of  injection  and  pressure.  If  an  ex- 
tremity i>  extensively  involved  amputation  will  probably  be  re- 
quired. 


CHAPTER    XXIX 
VARICOSE    VEINS,    VARICES,    PHLEBECTASIA 

Definition. — Varices  are  veins  which  have  become  permanently 
dilated;  they  have  lost  their  elasticity  and  are  often  tortuous. 

Arborescent  varicose  veins,  or  varicosities,  are  frequently 
observed  on  the  chest,  abdomen,  back,  and  thighs,  especially  of 
stout  individuals;  they  are  sufficiently  described  by  their  name, 
as  they  resemble  branching  twigs.  They  are  very  small  and  of  no 
clinical  importance. 

Etiology. — Usually  several  factors  combine  in  the  causation  of 
varicose  veins.  Disease  of  the  vessel  walls,  especially  inflamma- 
tory processes  which  weaken  the  resistance,  reduce  the  elasticity, 
replace  the  muscular  coats  with  fibrous  tissue,  and  cause  retrac- 
tion of  the  valves,  is  a  very  favorable  factor  in  their  establishment. 
If,  added  to  these  conditions,  conditions  are  present  which  interfere 
with  the  flow  of  blood  through  the  veins,  a  backward  pressure  is 
established  which  consummates  the  development  of  varices.  As 
the  backward  pressure  is  increased  the  nutrition  of  the  vein  walls 
is  diminished  and  the  characteristic  pathologic  changes  are  still 
further  favored.  The  backward  pressure  of  blood  is  favored  by 
both  anatomic  and  pathologic  changes,  as  well  as  by  physiologic. 
The  normal  erect  position  of  man  favors  the  development,  for 
instance,  of  hemorrhoids,  varicocele,  and  varices  of  the  long 
saphenous  vein  with  great  frequency.  The  absence  of  valves  in 
the  spermatic  veins  and  the  rectangular  junction  of  the  left  one 
with  the  left  renal  vein  especially  favors  left-sided  varicocele. 
The  presence  of  pelvic  tumors  and  thrombi  in  the  common  femoral 
or  iliac  veins,  as  well  as  cardiac  lesions,  produce  obstruction  very 
favorable  to  varices  in  the  long  saphenous. 

Hepatic  lesions  interfering  with  the  portal  circulation  favor 
internal  hemorrhoids.  Pregnancy,  constipation,  and  the  standing 
position  favor  the  development  both  of  hemorrhoids  and  of 
varices  in  the  long  saphenous. 

Heredity  must  be  mentioned  as  an  etiologic  factor,  as  an 
inherent  weakness  of  the  vessel  walls  may  unquestionably  be 
transmitted  by  parents  to  their  children. 

Pathology. — The  veins  themselves  are  usually  more  tortuous 
than  normal.  There  may  be  segments  that  appear  to  be  normal 
and  others  that  are  thinner  or  thicker  than  normal.  The  thick- 
ened portion  is  due  to  the  formation  of  fibrous  tissue,  and  the  thin 

424 


VARICOSE    VEINS,    VARICES,    PHLEBECTASIA  425 

bulging  spots  are  produced  by  excessive  dilatation.  Occasionally 
the  openings  into  these  dilated  segments  become  closed  and  blood- 
cysts  form,  or  two  or  more  of  them,  by  lying  in  contact,  lose  their 
intervening  walls  and  become  a  single  cavity.  The  tissues  sur- 
rounding varicose  veins  atrophy  somewhat  in  consequence  of  the 
continued  pressure;  this  is  especially  true  of  the  skin,  which  be- 
comes thin  along  the  course  of  the  vessels  and  often  ruptures. 
The  veins  are  more  closely  adherent  to  their  environs  than  nor- 
mally, and  may  be  densely  attached  to  them.  Within  the  veins 
the  blood-current  may  be  so  sluggish  that  thrombi  form.  By  organ- 
ization these  thrombi  may  produce  permanent  obliteration  of  the 
veins  and  result  in  a  more  or  less  complete  cure;  or  they  may  calcify 
and  remain  indefinitely  in  the  form  of  phleboliths,  or  vein-istones. 

Symptoms. — The  symptoms  produced  by  varices  are  chiefly 
indirect — i.  e.,  they  depend  on  nutritional  disturbances,  com- 
plications, and  mechanical  interference  with  function  rather  than 
upon  the  varices  per  se.  Hence,  the  individual,  usually  in  middle 
life,  twenty  to  fifty,  complains  of  discomfort,  for  example,  in 
the  lower  extremity,  especially  on  standing  or  walking  a  great  deal 
the  leg  becomes  tired  or  numb  and  aches.  These  symptoms  disap- 
pear on  rest  and  elevation.  In  many  cases  of  varicose  veins  of 
either  of  the  three  usual  types — viz.,  hemorrhoids,  varicocele,  or 
varices  of  the  lower  extremity — extensive  changes  may  occur 
with  no  discomfort  and  no  crippling  of  function.  On  the  contrary, 
moderate  developments  in  either  of  these  regions  may  cause  severe 
and  distressing  symptoms.  If  the  deep  veins  are  involved  it  is 
impossible  to  recognize  their  presence.  They  are  usually  aso- 
ciated  with  varices  in  the  superficial  veins.  Swelling  and  edema 
are  frequently  associated  with  varicose  veins  of  the  lower  extremity. 

On  examination  of  the  part  affected  there  is  usually  little 
difficulty  in  recognizing  the  true  condition  unless  complications 
obscure  the  field.  The  superficial  veins,  large  or  small,  or  both, 
in  the  leg  and  thigh,  the  two  saphenous  veins  and  their  tributaries 
appear  as  dilated,  tortuous,  nodular  cords  running  beneath  the 
skin,  through  which  the  color  of  the  blood  shows  blue,  the  color 
I  .ring  deeper  at  the  thinnest  spots.  The  cord-like  ridges  are  soft 
and  collapsible  on  pressure  and  disappear  on  uniform  compres- 
sion or  elevation  of  the  extremity,  only  to  return  on  release  of  the 
piv-Mire  <>r  resumption  of  the  dependent  position.  The  atrophy 
of  the  skin  and  connective  tissue  is  attested  by  the  groove-like 
feel  along  the  course  of  the  veins.  Thrombi  may  be  felt  if  present 
in  >uperficial  veins,  and  occasionally  phleboliths  are  recognized. 

Complications.-  Nutritive  disturbances  are  responsible  for 
mo«.t  of  the  complications  arising  from  varicose  veins.  In  varico- 
cele the  m«»t  .listre— iim  feature,  a-iile  from  the  possibility  of  pain, 


426  PRINCIPLES   OF   SURGERY 

is  atrophy  of  the  testicle,  as  shown  by  the  diminished  size  and  in- 
creased softness.  In  the  lower  extremity  the  chief  complications 
are  ulceration,  hemorrhage,  intractable  eczema,  thrombophlebitis, 
and  a  brawny,  indurated  edema,  which  may  so  thicken  the  tissues 
and  enlarge  the  leg  as  to  obscure  the  causative  varices  and  give  the 
appearance  almost  of  a  moderate  elephantiasis.  Ulceration  is  quite 
common,  and  usually  appears  hi  the  lower  half  of  the  leg.  The 
ulcers  may  be  minute  and  superficial  or  enormously  large  and 
deep.  They  are  chronic,  and  may  be  either  callous  or  erethistic. 
When  healed  they  tend  to  recur.  The  skin  of  these  legs  is  often 
pigmented  brown,  more  especially  if  ulceration  is  present.  Hemor- 
rhage occurs  on  the  surface  or  in  the  tissues.  It  occurs  on  the 
surface  as  a  result  of  traumatism  or  severe  muscular  effort;  the 
latter  cause  is  also  responsible  for  the  deep  hemorrhages.  Eczema 
is  often  responsible  for  the  chief  discomfort;  nothing  offers  perma- 
nent relief  for  it  so  long  as  the  veins  remain  untreated.  Throm- 
bophlebitis may  result  in  cure,  in  phleboliths,  or  in  inflammation 
and  suppuration.  Its  recurrence  at  frequent  intervals  is  extremely 
annoying  and  ulcers  are  apt  to  follow  it.  The  great  thickening 
of  the  tissues,  resembling  elephantiasis,  is  usually  associated  with 
ulceration,  which  in  its  turn  is  the  most  frequent  complication. 

Prognosis. — After  their  thorough  establishment  varicose  veins 
remain  permanently,  tending  only  to  grow  worse  or  to  develop 
their  annoying  or  dangerous  complications.  In  some  instances 
they  appear  during  pregnancy,  remain  until  parturition,  and  do  not 
reappear  until  the  next  pregnancy.  Such  cases  are  brought  to 
fully  developed  varices  by  repeated  gestations.  Varicose  veins  do 
not  endanger  life  per  se,  but  they  impair  the  usefulness  and  ac- 
tivity of  the  individual,  and,  aside  from  the  discomfort  produced 
by  their  interference  with  the  circulation,  may,  by  development  of 
complications,  result  in  the  complete  incapacity  of  their  host. 

Treatment. — The  treatment  of  varicose  veins  may  be  looked 
upon  as  preventive,  palliative,  and  curative.  The  treatment  of 
the  various  complications  is  nothing  different  from  that  of  similar 
lesions  arising  from  other  sources,  except  that  they  cannot  be 
satisfactorily  managed  until  the  varices  have  been  first  looked  to. 

Preventive  treatment  is,  of  course,  largely  a  removal  of  causes. 
Many  cases  could  be  avoided  entirely  by  avoiding  improper  prac- 
tices or  removing  mechanical  structures  which  are  known,  to 
result  at  times  in  this  condition.  Usually  the  veins  are  pretty 
well  advanced  hi  varicosis  before  the  surgeon  is  consulted,  and  his 
advice  is  only  valuable  hi  prevention  of  further  advancement. 
Such  advice,  then,  must  be  directed  against  all  mechanical  ob- 
struction, however  slight,  against  maintenance  of  the  standing  pos- 
ture for  long  periods,  as  in  bookkeeping,  and  toward  encourage- 


VARICOSE  VEINS,    VABICES,    PHLEBECTASIA  427 

ment  of  elevation  of  the  part  if  possible.  Walking  is  better  for  such 
patients  than  standing,  and  sitting  is  better  than  habitual  walking. 
The  function  of  the  heart  must  be  maintained,  the  bowels  must  not 
be  constipated.  If  the  varices  result  from  portal  obstruction,  their 
further  development  cannot  be  prevented,  except  where  it  is 
possible  to  remove  the  obstruction  surgically  or  by  therapeutic 
means,  or  to  establish  adequate  collaterals  to  relieve  the  portal 
vein  of  a  part  of  its  blood,  as  is  done  by  omentopexy. 

Palliative  treatment  consists  in  the  performance  of  all  that  has 
been  said  on  the  subject  of  preventive  treatment.  Preventive 
treatment  is  intended  to  accomplish  at  an  early  stage  exactly 
what  palliative  treatment  does  later.  Further,  palliative  treat- 
ment must  give  artificially  the  support  to  the  veins  that  they  have 
lost  in  their  change  from  the  normal  to  the  varicosed  condition. 
This  is  accomplished  by  the  use  of  elastic  bandages  or,  better, 
elastic  hose  made  of  silk  and  rubber,  and,  in  case  of  varicocele, 
well-fitted  suspensories.  The  use  of  massage  adds  something  to 
the  comfort  of  the  individual,  but  nothing  permanent.  Injuries 
are  to  be  avoided,  and  the  earliest  appearance  of  complications 
must  be  a  signal  for  prompt  attention. 

Curative  or  radical  treatment  is  always  surgical.  It  consists 
in  obliteration  or  removal  of  the  veins  affected.  The  plans  of 
obliteration  consist  in  the  application  of  ligatures  at  single  or 
numerous  points  in  the  course  of  the  veins,  with  or  without  ex- 
cision of  the  vessels  between  ligatures.  It  is  preferable  probably 
to  double-ligate  and  sever  the  veins.  The  most  frequently  em- 
ployed of  such  plans  are  Trendelenburg's  ligation  at  the  saphenous 
opening  and  Schede's  circumcision  (circular  incision  to  the  deep 
fascia  and  ligature  of  all  bleeding  points),  and  the  application  of 
ligatures  at  various  points  along  the  diseased  vessels.  Sometimes 
obliteration  is  practised,  ill-advisedly,  by  injection  of  escharotics 
into  hemorrhoids.  Multiple  ligature  may  be  practised  by  the 
open  or  subcutaneous  method;  the  former  is  preferable.  No 
curative  treatment  can  be  offered  where  both' superficial  and  deep 
veins  are  varicosed. 

Removal  of  the  veins  is  the  most  satisfactory  plan  of  treat- 
ment. It  is  illustrated  by  the  various  methods  of  excising  hemor- 
rhoids, almost  universally  practised,  by  Bennett's  operation  for 
varicocele  by  double  ligation  and  excision  of  the  intervening 
segment  and  approximation  of  the  stumps,  and  by  the  ordinary 
excision  of  varices  in  superficial  veins  through  incisions  coextensive 
with  the  length  of  vein  excised,  or  by  Mayo's  plan  of  making  short 
in<  i-ions  at  long  intervals,  removing  the  intervening  portion  of 
vein  with  an  enucleator. 

Radical  cure  of  varicose  veins  must  not  l>e  undertaken  when 
the  deej)  veins  have  previously  been  obliterated. 


CHAPTER    XXX 
LYMPHANGIECTASES  AND  LYMPH-EDEMA 

THE  causes  of  this  condition,  which  result  in  interference  with 
the  lymph-circulation  sufficiently  to  cause  filling  and  dilatation  of 
the  lymph-channels  and  spaces,  are  either  obstruction  or  oblitera- 
tion of  the  lymph-vessels.  Pressure  by  tumors  and  pathologic 
accumulations,  as  ascites,  and  by  scar-tissue  may  collapse  the 
vessels;  they  may  be  blocked  by  the  direct  growth  of  cancerous 
tissue  into  the  channels  or  by  the  presence  of  Filaria  sanguinis- 
hominis  (see  Elephantiasis),  or  by  occlusion  or  obliteration  of  the 
channels  by  thrombi  which  develop  as  a  sequel  to  repeated  inflam- 
mations, as  in  recurrent  attacks  of  erysipelas. 

In  case  of  obstruction  of  the  lymph-current  the  vessels  dilate 
and  become  more  or  less  tortuous,  and  may  be  seen  or  felt  beneath 
the  skin,  appearing  much  as  varicose  veins,  but  not  reaching  so 
great  a  size,  and,  of  course,  without  the  bluish  color  of  the  latter. 
The  skin  becomes  swollen  and,  to  all  appearance,  edematous, 
pitting  on  pressure,  and  presenting  a  peculiar  whitish  appearance 
not  observed  in  other  conditions.  The  swelling  shades  off  gradually 
into  the  surrounding  normal  tissue.  Occasionally  dilated  vessels 
appear  the  size  of  a  large  shot,  and  smaller  vesicles  may  cover  the 
whole  affected  areas.  The  swollen  surface  pits  on  pressure,  just  as 
in  ordinary  edema.  When  the  thoracic  duct  is  obstructed  the  walls 
may  rupture  and  cause  an  effusion  of  chyle  into  the  pleural  (chylo- 
thorax)  or  the  peritoneal  cavity  (chylous  ascites).  Injuries  of 
the  skin,  however  slight,  are  to  be  avoided  in  cases  of  lymphan- 
giectasis,  as  the  channels  and  spaces  are  easily  penetrated  and  a 
large  discharge  of  lymph  will  continue  to  escape,  often  in  spite  of 
our  best  efforts  to  control  them.  The  loss  of  lymph  does  not 
impress  the  patient  unfavorably,  but  its  continued  presence  on  the 
skin  surface  will  macerate  and  irritate  the  skin. 

Lymphangiectatic  tissues  are  very  easily  infected  and  are 
susceptible  to  repeated  inflammation. 

The  prognosis  of  lymphangiectasis  is  unfavorable  when  the 
vessels  are  completely  obliterated;  in  those  cases  where  the  ob- 
literation is  not  so  extensive  the  remaining  vessels  may  be  able  to 
assume  the  requisite  additional  function  similar  to  the  collateral 
circulation  in  obstruction  of  blood-vessels.  There  is  little  danger 

428 


LYMPHANGIECTASES    AND    LYMPH-EDEMA  429 

to  life  or  limb  except  such  as  the  complications  or  the  cause  may 
entail. 

Treatment. — The  course  to  pursue  is  indicated  by  the  cause 
and  by  the  extent  of  the  lesion.  If  the  cause  of  obstruction  can 
be  removed  the  lymphangiectatic  edema  will  disappear;  if  there 
are  larger  lymphangiectases,  they  should  be  dissected  away. 
If  there  is  reason  to  believe  that  the  case  is  not  one  of  complete 
and  permanent  obstruction,  relief  may  follow  uniform  pressure  and 
elevation.  When  fistulae  appear  they  are  to  be  dealt  with  by 
cauterization  and  pressure  or  by  incision  and  packing,  unless  the 
case  can  be  radically  relieved  by  excision. 

In  cases  of  lymph-edema  and  lymphangiectases  of  large  extent 
the  plan  of  establishing  new  routes  for  the  lymph  flow  by  trans- 
planting the  fascia  has  been  undertaken,  but  it  has  not  been  pur- 
sued far  enough  to  make  satisfactory  observations. 


CHAPTER    XXXI 
ELEPHANTIASIS,   ACQUIRED    PACHYDERMIA 

Definition. — This  condition  is  a  hyperplasia  of  the  skin  and 
subcutaneous  tissues;  the  cuticle,  too,  is  often  hyperplastic. 
Even  the  intramuscular  connective  tissues  may  be  affected,  due 
to  interference  with  the  circulation  of  lymph. 

Etiology. — The  causes  of  elephantiasis  are  not  uniformly  the 
same.  The  majority  of  the  cases  are  undoubtedly  produced  by  the 
parasite  Filaria  sanguinis-hominis  (elephantiasis  filariosa) ,  indige- 
nous in  the  tropics,  where  by  far  the  greater  number  of  cases  occur. 
This  parasite  in  its  adult  state  is  capable  of  blocking  the  lymph- 
channels  sufficiently  to  obstruct  the  lymph  flow  and  cause  ele- 
phantiasis, which  occurs  by  no  means  in  all  infected  cases,  some 
tropical  countries  showing  the  filaria  probably  in  12  per  cent,  of  the 
population,  the  majority  of  whom  are  and  remain  in  good  health. 
Elephantiasis  arabum  is,  therefore,  to  be  recognized  as  a  compli- 
cation that  may  arise  in  these  cases.  The  larval  stage  of  filaria  is 
passed  in  the  blood,  and  they  can  be  easily  demonstrated  micro- 
scopically in  blood  drawn  during  the  habitual  resting  hours,  hence 
usually  at  night. 

A  second  cause  of  elephantiasis  (E.  nostras)  is  repeated  in- 
flammatory processes  in  the  skin,  such  as  erysipelas  and  eczema. 
The  lesion  may  be  congenital  and  grow  gradually  worse,  especially 
if  frequent  inflammation  occurs,  as  it  is  prone  to  do.  A  condition 
resembling  elephantiasis  very  closely  (E.  phlebectatica)  is  often 
associated  with  varicose  veins  of  the  leg.  Similar  lesions  are  also 
often  associated  with  chronic  ulceration.  The  latter  two  causes, 
however,  do  not  usually  produce  the  enormous  changes  seen  in 
elephantiasis. 

Finally,  there  is  a  condition  known  as  elephantiasis  neuro- 
matosa,  associated  sometimes  with  von  Recklinghausen's  disease, 
and  usually  affecting  one  lower  extremity.  It  differs  from  elephan- 
tiasis in  the  absence  of  edema  and  the  presence  of  the  enlarged 
nodulated  nerves. 

Pathology. — The  changes  produced  in  elephantiasis  are  due 
to  a  hyperplasia  of  the  connective  tissue.  The  skin  and  subcu- 
taneous tissue  are  chiefly  affected;  the  epidermis  may  also  be  hy- 
perplastic. However,  in  the  more  severe  cases  the  intramuscular 
septa  may  be  affected  and  the  fat  and  muscular  tissue  may  be 

430 


ELEPHANTIASIS,  ACQUIRED  PACHYDERMIA 


431 


destroyed  by  the  gradual  development  of  connective  tissue. 
Periostitis  sometimes  forms  a  part  of  the  pathologic  picture  and 
the  bones  may  be  irregularly  thickened.  Occasionally  osteomata 


Fig.  86. — Case  of  elephantiasis  from  which  streptococcus  and  Bacillus  prodig- 
iosus  were  recovered  (McCabe). 

appear  in  the  connective  tissue  of  the  skin.  The  hyperplasia 
forms  either  a  dense,  firm  mass  of  tissue  or  a  less  dense,  softer  struc- 
ture of  "edematous,  gelatinous  tissue." 


I"\K.  S7. — Another  view  of  s:un<-  c:i>r  >li<.un  in  Fig.  86  (McCabe). 

Diagnosis. — The   regions   commonly   affected   are   the   lower 

extremities  tin-  penis  and  scrotum,  the  labia  and  the  clitoris. 
It  is  occasion;i lly  observed  in  other  parts.  The  parts  become  un- 
naturally enlarged,  often  many  times  their  original  si/e,  so  that 


432 


PRINCIPLES   OF   SURGERY 


the  leg  may  measure  three  or  four  times  its  normal  circumference, 
the  scrotum  or  the  labia  may  reach  far  below  the  knees,  and  the 
clitoris  may  reach  the  size  of  a  well-developed  penis,  and  hi  ap- 
pearance and  shape  look  wholly  unlike  the  normal  structure. 
The  surface  may  be  hard  and  board-like  or  soft  and  edematous. 
The  skin  surface  may  be  nodular,  or  covered  with  papillae,  or  en- 
tirely smooth;  it  is  sometimes  scaly,  as  in  ichthyosis.  The  skin  may 


Elephantiasis  in  a  negro  woman. 


be  either  translucent  or  pigmented.  The  creases  and  folds  of  the 
skin  are  much  deeper  than  normal  and  the  opposed  skin  surfaces 
are  moist,  macerated,  and  foul  smelling. 

From  a  subjective  standpoint  little  or  no  discomfort  may  be 
felt  except  the  incumbrance  of  the  gradually  increasing  weight  of 
an  unweildly  part.  On  the  other  hand,  the  discomfort  may  amount 
to  intense  suffering,  both  from  the  burden  of  the  enlarged  part,  its 


ELEPHANTIASIS,    ACQUIRED    PACHYDERMIA  433 

loss  of  function,  and  the  pain  endured.  This  pain  is  of  the  neural- 
gic type,  and  continues  during  the  development  of  elephantiasis, 
but  disappears  or  is  reduced  later  by  the  gradual  destruction  of 
nerve  tissue. 

Complications. — Elephantiasis  is  subject  to  the  same  com- 
plications as  lymphangiectasis.  Infection,  ulceration,  eczema, 
abscess,  and  leakage  of  lymph  from  ulcerated  or  wounded  surfaces 
prevail.  In  addition,  the  changes  of  atrophy  and  degeneration 
of  normal  structures  of  the  nerves  and  irregular  thickening  of  the 
bones  are  common. 

Prognosis. — The  outlook  for  the  local  disturbance  is  bad;  the 
danger  to  life  depends  on  intercurrent  conditions,  especially 
inflammatory  processes.  Elephantiasis  filariosa  is  occasionally  re- 
lieved by  removal  to  a  non-infected  region. 

Treatment. — A  few  cases  of  elephantiasis  filariosa  are  cured 
spontaneously  by  change  of  climate.  Aside  from  this,  the  treat- 
ment is  entirely  surgical  once  elephantiasis  has  fully  developed. 
The  affected  structure  may  be  removed  if  possible,  and  this  may 
require  amputation  at  the  upper  limit  of  the  affected  region. 
It  should  be  impressed  that  the  tissues  in  these  cases  do  not  heal 
readily,  and  that  they  are  poorly  resistant  to  pyogenic  bacteria. 
If  the  diseased  tissue  is  so  situated  that  it  cannot  be  safely  re- 
moved, and  if  of  limited  extent,  as  in  lymphadenocele,  the  injection 
of  escharotic  solutions  has  been  recommended.  It  will  be  safer 
and  probably  more  beneficial  to  inject  them  with  boiling  water, 
as  is  done  in  cavernous  angiomata. 

RHINOPHYMA 

This  condition  may  be  defined  as  an  elephantiasis  of  the  nose 
affecting  individuals,  usually  whisky  drinkers,  who  have  passed 
middle  life.  It  is  usually  preceded  by  acne  rosacea,  and  continues 
to  grow  worse  with  increased  years.  The  nose  is  violently  red, 
enlarged,  and  elongated,  its  tip  sometimes  reaching  the  level  of 
the  mouth  or  lower.  It  presents  a  nodulated  appearance,  is  soft, 
and  not  edematous.  The  connective  tissue  is  increased  in  quantity 
and  there  is  an  associated  hyperplasia  of  the  sebaceous  glands  which 
often  contain  pus.  The  vessels  in  the  skin  are  visible.  Similar 
nodules  may  appear  elsewhere  on  the  face. 

The  treatment  of  this  condition  consists  in  removal  of  the 
superfluous  tissue  either  l.y  the  knife  or  the  actual  cautery.  The 
pim-  n moved  may  be  wedge  shaped  or  they  may  be  cut  parallel 
to  the  surface.  If  epidermi/ation  is  incomplete,  skin-grafting 
is  to  be  done.  Hemorrhage  is  extensive  in  cutting  operations  for 
this  condition. 
28 


CHAPTER    XXXII 
ANESTHESIA 

ANESTHESIA  may  be  conveniently  classified  as  local  and 
general.  In  local  anesthesia  it  is  the  intention  to  suspend  sen- 
sibility (especially  that  for  pain)  in  the  part  to  be  operated  on, 
or  in  a  region  which  embraces  the  field  of  operation.  General 
anesthesia  produces  not  only  entire  loss  of  sensibility,  but  of  con- 
sciousness as  well. 

Local  Anesthesia. — Local  anesthesia  is  produced  in  two  ways, 
namely,  by  the  applications  of  cold,  and  by  the  employment  of 
drugs  which  so  act  upon  the  nerve-endings  or  then-  fibers  that  no 
stimuli  are  received  or  transmitted  by  them. 

The  employment  of  cold  for  the  production  of  anesthesia  is  of 
very  limited  usefulness,  being  restricted  to  superficial  lesions. 
When  the  depth  of  an  incision  must  be  much  greater  than  the 
thickness  of  the  skin  this  method  is  unsatisfactory;  it  is  likewise 
available  only  when  the  necessary  work  requires  only  a  few  sec- 
onds for  its  performance. 

Anesthesia  is  produced  by  any  compound  or  mixture  that  will 
freeze  the  surface.  The  drug  employed  usually  is  ethyl  chlorid, 
which  should  be  sprayed  on  the  surface  until  the  latter  is  covered 
with  a  coat  of  white  frost,  when  the  work  must  proceed  at  once. 
Carbon  dioxid  is  colder,  more  easily  handled,  and  hi  the  cities 
much  cheaper  than  ethyl  chlorid,  and  can  be  applied  and  confined 
to  the  desired  area  much  more  easily;  it  is  molded  into  the  proper 
shape  and  held  in  contact  with  the  tissues  for  ten  to  thirty  seconds. 
Quicker  and  more  satisfactory  anesthesia  is  produced  if  the  lump 
of  snow  can  be  pressed  firmly  enough  against  the  part  to  obstruct 
capillary  circulation.  Cold  should  not  be  employed  as  an  anes- 
thetic in  individuals  whose  tissue  resistance  is  poor,  especially  in 
diabetics. 

The  drugs  possessed  of  anesthetic  properties  are  numerous. 
The  more  common  ones  are  carbolic  acid,  magnesium  sulphate, 
cocain,  eucain,  stovain,  and  novocain.  Of  these  the  most  fre- 
quently employed  is  cocain,  of  which  the  full  dose  is  1  gr. 
Eucain  is  used  hi  the  same  way,  and  the  dose  is  the  same  as  cocain. 
It  is  said  to  be  less  toxic.  Novocain  is  similar  in  action  to  the 
others,  but  the  maximum  dose  may  be  as  high  as  8  gr.  when 
employed  in  extradural  anesthesia. 

434 


ANESTHESIA  435 

The  methods  of  employing  these  drugs  are  by  absorption, 
by  endermic  injection,  by  infiltration  (Schleich),  by  hypodermic 
injection,  by  injection  into  nerves  (nerve  blockage),  by  intra- 
venous injection,  by  intradural  injection  (intraspinal  analgesia), 
and  by  epidural  injection. 

Raw  surfaces,  granulating  wounds,  and  especially  mucous 
membranes  can  be  satisfactorily  anesthetized  superficially  by 
holding  rather  strong  cocain  solutions  (5  to  10  per  cent.)  in  contact 
with  them  for  a  period  of  from  five  to  fifteen  minutes.  The  tonsils 
and  adenoids  are  thus  especially  susceptible  because  of  their 
great  absorptive  power.  Bleeding  wounds  cannot  be  anesthetized 
well  by  this  plan,  and  it  is  employed  in  general  more  as  a  prepara- 
tion for  instrumentation  than  for  operation,  except  on  mucous 
surfaces. 

The  endermic  plan  for  local  anesthesia  is  to  inject  anesthetic 
solutions  into  the  skin  sufficiently  to  raise  a  white  bleb  along  the 
course  of  the  proposed  incision.  Anesthesia  is  instantaneous,  and 
depends  more  on  the  physical  action  of  the  fluid  mass  on  the  nerve- 
fibers  and  endings  than  on  the  anesthetic  contained,  as  is  attested 
by  the  dilute  solutions  of  cocain  required  (jV  to  £  of  1  per  cent.), 
or  by  the  similar  action  of  fluids  which  possess  no  anesthetic  proper- 
ties. This  plan  is  carried  still  further  in  hypodermic  anesthesia,  as 
was  first  impressed  by  Schleich  (see  Schleich's  solution).  Anesthe- 
sia is  produced  in  the  subcutaneous  structures  hi  the  same  way  as 
in  the  skin  by  the  injection  of  large  quantities  of  weak  solutions 
of  cocain  or  eucain,  and  this  plan  is  much  more  satisfactory  in  more 
e\t eiusive  operations  than  the  injection  of  limited  quantities  of 
stronger  solutions,  because,  by  using  the  larger  volumes  of  fluid, 
not  only  are  all  the  tissues  reached,  but  the  combined  mechanical 
anesthetic  values  of  the  fluid  are  attained.  Thus,  one  may  easily 
do  herniotomy,  goiter,  and  hemorrhoid  operations  by  local  anes- 
the>ia,  provided  no  rough  handling  of  the  tissues  be  engaged  in, 
an  inexcusable  practice  even  when  the  patient  is  profoundly 
under  general  anesthesia.  * 

Nerve-blocking  is  employed  in  producing  local  anesthesia,  as 
by  this  plan  the  injection  of  2  or  3  minims  of  a  1  or  2  per  cent, 
solution  of  cocain  into  the  nerve-sheath  will  completely  anes- 
theti/e  its  whole  (list  ril  nit  ion.  Of  course,  when  a  region  is  supplied 
l»y  more  than  one  sensory  nerve  all  must  be  treated  hi  the  same 
manner.  Nerve-block inu;  demands  only  small  doses  of  cocain, 
whereas  by  the  hypodermic  or  the  infiltration  method  toxic  doses 
would  be  requisite  to  produce  even  much  ]w>orer  results.  The 
nerves  are  reached  through  incisions,  the  anesthesia  for  which 
was  produced  by  infiltration.  By  these  combined  methods  such 
major  operations  as  resection  of  the  upper  and  lower  jaws  can  be 


436  PRINCIPLES   OF   SURGERY 

satisfactorily  done;  while  it  is  ideal  for  such  minor  operations  as 
the  amputation  of  fingers  and  toes,  in  which  an  attempt  is  made 
to  inject  the  solution  in  the  region  of  the  nerves,  but  not  to  locate 
and  inject  them  individually.  Amputations  of  the  hand  or  foot 
may  be  similarly  executed.  This  plan  of  blocking  is  frequently 
rendered  necessary  .by  the  presence  of  inflammation  in  the  part  to  be 
operated,  rendering  direct  anesthesia  of  the  part  inadvisable. 

Intravenous  local  anesthesia  has  recently  been  extensively  em- 
ployed by  German  surgeons.  After  rendering  the  part  bloodless 
by  the  Esmarch  plan  a  tourniquet  is  applied  above  and  another 
below  the  operative  field,  and  a  solution  of  cocain  injected  into  a 
vein  between  the  two.  This  follows  the  various  distribution  of 
the  vessels  of  the  part  and  anesthetizes  the  entire  volume  em- 
braced between  the  tourniquets,  so  that  operations  of  any  degree 
may  be  done. 

Intraspinal  analgesia  is  in  necessary  cases  a  very  useful  plan, 
but  it  must  be  looked  upon  only  as  an  unsafe  and  unsatisfactory 
alternative  when  other  plans  cannot  be  employed.  Here  the 
cocain  (or  stovain)  solutions,  |  to  2  per  cent.,  are  injected  hi  5- 
minim  doses  through  the  third  and  fourth  lumbar  interspace  into 
the  subarachnoid  space  of  the  cord.  No  injection  should  be  made 
until  the  needle  has  been  placed  so  that  cerebrospinal  fluid  escapes. 
The  method  is  not  as  safe  as  general  anesthesia,  and  should  be  used 
only  when  the  latter  is  positively  contra-indicated.  Anesthesia  is 
not  always  complete,  and  the  sequelae  are  often  more  disagree- 
able than  those  of  general  anesthesia.  The  blood-pressure  is 
reduced;  nausea,  vomiting,  headache,  and  fever  follow.  Intra- 
spinal analgesia  is  a  special  plan  of  nerve-blocking,  and  here  as 
elsewhere  anesthesia  is  produced  only  in  the  part  distal  to  the  site 
of  injection. 

Sacral  anesthesia  is  the  latest  adventure  in  nerve-blocking. 
It  is  extradural  injection  of  anesthetic  solutions  into  the  sacral 
canal,  and  safely  anesthetizes  a  very  definite  group  of  structures. 
Cocain  cannot  be  given  in  sufficient  dosage ;  novocain  is  employed 
instead.  The  formula  recommended  by  Siebert  is  as  follows: 

Sod.  bicarb.,  C.  P.  Merk 0.2    gm. 

Sod.  chlorat 0.2    gm. 

Novocain 0.75  gm. 

Aq.  dest 50       c.c. 

Twenty  to  25  c.c.  of  this  solution,  after  momentary  boiling 
and  the  addition  of  5  minims  of  adrenalin  chlorid,  1 : 1000,  is  injected 
into  the  sacral  canal  through  the  membrane  which  marks  its  lower 
limit,  the  hiatus  sacralis ;  the  patient  remains  in  the  sitting  posture 
from  eight  to  twenty-five  minutes,  or  until  anesthesia  is  complete, 


ANESTHESIA  437 

and  then  assumes  the  position  required  for  the  operation.  It  is 
employed  in  all  cases  where  the  operative  field  is  supplied  by  the 
distribution  of  the  sacral  plexus,  namely,  in  "prolapsus  ani,  hemor- 
rhoids, perineorrhaphy,  and  other  procedures  in  the  perineal  and 
genital  regions;  furthermore,  in  obstetric  operations." 

Similarly,  epidural  anesthesia  is  being  employed  for  anesthetiz- 
ing the  dorsal  and  lumbar  nerves. 

The  advantages  of  local  anesthesia  are  manifest.  The  pre- 
operative  preparations  for  general  anesthesia  are  avoided,  and 
postoperative  discomfort  is  spared  the  patient.  The  danger  is 
less,  the  time  of  operation  in  minor  cases  shorter,  and  the  expense 
is  not  so  high.  But  especially  those  major  cases  where  general 
anesthesia  is  contra-indicated,  on  account  of  the  general  condition 
of  the  patient,  on  account  of  the  nature  of  the  operation  or  the 
pathology  for  which  it  is  offered,  local  anesthesia  has  a  much 
wider  and  more  useful  field  than  it  has  received  at  the  hands  of 
the  profession. 

Local  anesthesia  may  be  prolonged  somewhat,  usually  by 
combining  adrenalin  chlorid  with  it,  unless  the  latter  is  contra- 
in<  Heated  or  feared,  owing  to  the  possibility  of  secondary  hemor- 
rhage. 

General  Anesthesia. — General  or  pulmonary  anesthesia  is 
produced  by  the  inhalation  of  the  vapors  of  various  drugs  which 
are  liquid  or  gaseous  in  their  natural  state,  such  as  ether,  chloro- 
form, nitrous  oxid,  ethyl  chlorid,  and  ethyl  bromid;  by  combina- 
tions of  these,  for  example,  alcohol-ether-chloroform  mixture 
(A.  C.  E.),  and  by  using  two  or  more  of  them  in  succession. 

Prior  to  administration  of  a  general  anesthetic,  in  all  except  the 
most  in.-i>t( -at  emergency  cases,  a  thorough  physical  examination 
of  the  patient  should  be  made. 

Physical  Examination. — This  should  be  such  as  to  determine 
as  accurately  as  possible  the  condition  of  the  heart,  lungs,  kidneys, 
and  throat  especially;  and  of  less  frequent,  but  not  less  great  im- 
portance, the  general  condition,  as  one  often  sees  cases  in  which 
there  is  no  question  about  the  need  for  surgery,  but  a  very  grave 
oni-  relative  to  the  patient's  ability  to  tolerate  anesthesia.  If  it 
is  possible  to  determine  the  condition  known  as  status  lymph- 
aticus  it  should  be  accepted  as  a  bar  to  all  forms  of  general  anes- 
the>ia,  except  in  the  most  urgent  cases.  The  history  of  the  patient 
oeea.-ionally  reveals  the  fact  that  a  previous  anesthetic  has  almost 
proved  fatal.  In  all  cases  where  general  anesthesia  is  contra- 
indicated,  it  should,  if  possible,  be  supplanted  by  local  anesthesia. 
In  general,  ether  is,  from  a  theoretic  standpoint,  contra-indicated 
hi  cases  of  pulmonary  l«->ions.  tuberculosis  and  severe  bronchitis, 
and  in  cases  of  nephritis.  Many  surgeons,  however,  use  it  in  all 


438  PRINCIPLES   OF   SURGERY 

their  work,  as,  with  improved  methods  of  administration,  it 
produces  apparently  less  harm  than  any  other  anesthetic,  and 
avoids  the  objectionable  feature  of  irritation  manifested  by  the 
old  plan  of  administration.  Chloroform  is  contra-indicated,  espe- 
cially in  all  cases  who  have  heart  lesions  or  disease  of  the  heart 
muscle,  and  is  absolutely  to  be  tabooed  in  status  lymphaticus 
and  in  patients  who  have  recently  had  diseases  which  frequently 
affect  the  heart,  such  as  diphtheria. 

Preparation  should  be  begun  a  sufficient  time  prior  to  the  hour 
for  anesthesia.  In  the  first  place,  every  patient's  mouth  should 
be  put  into  a  sanitary  condition  by  a  competent  dentist  a  few  days 
before  operation.  This  precaution  is  a  great  step  toward  the 
prevention  of  postanesthetic  pneumonia,  and  should  be  insisted 
upon.  The  sanitary  condition  should  then  be  maintained  by  the 
use  of  a  tooth-brush  and  a  sanitary  lotion  or  powder,  all  of  which 
to  this  day  are  strangers  to  many  patients.  The  upper  air-pas- 
sages should  be  cleansed  if  there  is  a  chronic  excess  of  secretion, 
and  the  operation  should  be  postponed,  if  possible,  if  there  is  an 
acute  inflammation  of  the  respiratory  tract.  The  stomach  should 
be  and  remain  empty  for  several  hours  prior  to  the  operation;  no 
food  should  be  allowed  within  ten  or  twelve  hours;  long  periods  of 
starvation  are  ill  advised  except  in  gastro-intestinal  work.  Water 
may  be  taken  in  moderate  quantities  up  to  the  time  of  operation. 
If  the  stomach  contains  food  at  the  tune  of  operation  it  should  be 
emptied  by  lavage.  The  bowels  should  be  emptied  by  a  moderate 
purge  two  days  prior  to  operation  and  by  enema  the  evening  and 
the  morning  before  operation.  Severe  purgation  should  not  be 
allowed,  and  purgation  within  twenty-four  hours  preceeding 
operation  is  not  so  satisfactory  as  an  earlier  one,  aside  from  being 
objectionable  on  technical  grounds  hi  surgery  of  the  alimentary 
tract.  For  several  hours  prior  to  operation  the  patient  should 
be  kept  quiet  in  bed. 

The  choice  of  an  anesthetic  is,  aside  from  what  has  been  said 
above,  determined  largely  by  the  duration  and  nature  of  the 
operation,  often  by  the  caprice  of  the  surgeon.  In  cases  of  short 
operation,  where  rigidity  and  tremor  cannot  interfere  with  the 
work,  or  where  an  expert  can  administer  it,  nitrous  oxid  may  be 
used;  ethyl  chlorid  has  the  same  advantages  and  disadvantages 
of  quick  anesthesia,  early  recovery,  rigidity,  and  tremor.  Chloro- 
form is  preferred  by  many  in  similar  cases,  and  possesses  the  ad- 
vantages without  the  disadvantages  of  the  other  two;  with  it 
prolonged  anesthesia  may  be  produced  if  necessary;  and,  while 
this  has  been  done  with  nitrous  oxid  administered  with  oxygen 
or  by  ethyl  chlorid,  the  practice  has  comparatively  few  adherents. 
So  far  as  practice  in  general  work  is  concerned,  ether,  chloroform, 


ANESTHESIA  439 

and  nitrous  oxid  are  the  standard  anesthetics,  and  in  the  United 
States  ether  is  employed  singly  or  in  conjunction  with  nitrous 
oxid  by  the  great  majority  of  surgeons. 

The  Relative  Danger  of  Anesthetics. — Aside  from  special 
dangers  arising  from  anesthesia  in  patients  who  have  certain 
pathologic  conditions,  there  is  an  element  of  danger,  small  but 
not  to  be  forgotten,  in  the  administration  of  anesthetics  in  general. 
A  drug  that  is  powerful  enough  to  cause  loss  of  consciousness  and 
sensibility  can,  when  pushed  far  enough,  or  in  the  presence  of 
certain  often  obscure  conditions  in  the  body,  and  with  the  aid  of 
certain  stimuli  or  traumatisms,  produce  death.  Hence,  not  only 
should  the  danger  of  anesthesia  be  recognized  by  the  surgeon,  but 
the  patient  should  be  apprised  of  this  danger  in  general,  and  also 
of  any  special  danger  in  his  own  case.  The  mortality  from  anes- 
thetics is  small,  but  it  is  just  as  likely  to  occur  in  those  who  are 
anesthetized  for  slight  as  for  severe  operations.  The  safest  anes- 
thetic  is  nitrous  oxid,  with  a  mortality  of  one  in  250,000  or  300,000; 
ft  her  comes  second  with  a  death-rate  of  1  in  18,000  to  25,000; 
chloroform  kills  1  in  3000  to  5000.  The  death-rate  from  ethyl 
chlorid  is  not  worked  out  sufficiently  to  be  dependable,  but  is 
probably  between  ether  and  chloroform,  and  that  of  A.  C.  E.  is 
not  established. 

The  causes  of  death  from  anesthesia  are:  (1)  Paralysis  of  the 
heart  during  incomplete  anesthesia,  especially  if  chlorofom  is  being 
used;  this  is  apt  to  occur  from  disturbance  of  the  patient  by  be- 
ginning to  operate  too  soon,  especially  in  the  region  of  the  fifth 
nerve.  (2)  From  asphyxiation,  as  occurs  when  the  air-passages  are 
obstructed  by  foreign  bodies,  enlarged  tonsils  and  adenoids,  or  by 
tin-  tonjjue,  and  when  the  lungs  are  filled  with  mucus,  as  in 
bronchorrhea,  or  when  vomitus  or  blood  is  sucked  into  the  trachea. 
(3)  By  paralysis  of  the  heart  or  respiration  from  overdosage  of 
the  anesthetic.  The  highest  centers  are  anesthetized  first,  then 
the  centers  of  motion  and  sensation,  the  vital  centers  last.  (4) 
By  the  combined  shock  produced  by  anesthesia  and  operation. 
It  must  be  borne  constantly  in  mind  that  shock  occurs  inde- 
pendently of  hemorrhage,  and  that  it  may  be  produced  during  full 
aiK-the-ia  a<  certainly  as  in  its  absence;  the  surgeon  should, 
therefore,  deal  a-  gently  with  the  tissues  as  possible,  whether  the 
anesthetic  be  local  or  general.  If  the  danger  of  shock  is  antici- 
pated in  such  operations  as  the  larger  amputations,  it  may  be 
reduced  to  a  minimum  l»y  blocking  the  larger  nerves  with  cocain 
before  severing  them.  Crushing.  l>rui.-ing,  tearing  the  tissues, 
e-peeially  the  nerves,  adds  to  the  shock  produced.  In  all  cases 
likely  to  be  attended  with  shock  constant  watch  should  be  held 
on  the  hlood-pressure. 


440  PRINCIPLES   OF   SURGERY 

Surgical  Anesthesia. — The  room  should  be  quiet  and  free  from 
an  audience,  but  there  should  always  be  at  least  one  attendant 
besides  the  anesthetist.  The  anesthetic  should  be  given  in  small 
quantity  at  the  beginning  by  an  assistant  who  is  able  to  gam  and 
to  hold  the  confidence  of  the  patient.  If  this  can  be  done,  and  if 
the  anesthetic  is  not  pushed  too  rapidly,  the  anesthetist  will  in 
some  way  cause  the  patient's  attention  to  be  directed  away  from 
the  anesthetic  by  causing  him  to  interlock  his  fingers,  to  count  or 
listen  to  occasionally  repeated  assurances  made  by  the .  anes- 
thetist. In  a  word,  if  a  bit  of  suggestion  is  combined  with  the 
anesthetic  the  course  will  be  much  easier,  and  the  formerly  de- 
scribed second  stage,  or  stage  of  excitement,  will  be  eliminated  or 
much  less  marked.  In  cases  where  the  patients  are  very  nervous 
or  excitable,  as  in  exophthalmic  goiter,  Crile  has  very  wisely  sug- 
gested that  the  patient  be  ignorant  of  the  time  and  the  fact  of 
anesthesia  by  daily  allowing  him  to  inhale  different  drugs  through 
the  cone,  so  that  he  will  consider  the  real  anesthetic  as  a  matter  of 
daily  routine  and  be  anesthetized  without  knowing  it.  Such  cases 
are  especially  benefited  by  a  dose  of  morphin  or  morphin-hyoscin- 
scopolamin  a  half-hour  or  an  hour  before  beginning  the  anesthetic. 

As  the  anesthetic  is  given  the  patient  should  be  carefully  ob- 
served by  the  anesthetist  for  any  untoward  change  in  his  condi- 
tion, who  should  give  notice  at  once  if  it  is  serious.  Administer- 
ing the  anesthetic  should  occupy  one  assistant's  entire  attention, 
and  he  should  not  be  tempted  from  his  post  by  a  desire  to  see  the 
details  of  the  operation. 

When  surgical  anesthesia  is  attained  it  may  be  recognized  by 
the  disappearance  of  the  reflexes.  The  eyes  look  straight  away 
during  surgical  anesthesia,  and  they  do  not  move,  as  in  the  in- 
complete stage,  by  rolling  aimlessly  and  slowly  or  by  a  nystagmic 
movement.  Sensation  is  lost;  this  is  determined  by  touching 
the  conjunctiva  (which  is  not  a  wise  practice)  or  by  pressing  over  a 
sensory  nerve,  as  the  supra-orbital.  The  experienced  anesthetist 
can  usually  recognize  surgical  anesthesia  by  the  relaxation  and  the 
more  or  less  characteristic  respiration,  which  is  even  and  moder- 
ately full.  In  the  administration  of  ether  there  is  frequently  a 
moderate  snoring;  it  should  not  amount  to  marked  stertor.  In 
chloroform  anesthesia  the  respiration  is  usually  very  quiet. 

Once  surgical  anesthesia  is  attained,  it  should  be  the  anes- 
thetist's purpose  to  hold  the  patient  as  superficially  under  it  as 
possible,  remembering  always  that  there  are  certain  parts  of  an 
operation  which  require  deeper  anesthesia  than  others.  The 
skin  and  external  mucous  membrane  are  most  sensitive  and  others 
are  often  completely  insensible,  for  example,  the  brain  and  the 
peritoneum.  The  anus  is  extremely  sensitive,  especially  to  divul- 


ANESTHESIA  441 

sion,  and  the  anesthetist  should  be  notified  when  such  a  proced- 
ure is  about  to  be  undertaken,  particularly  if  chloroform  is  being 
pven,  lest  the  resultant  deep  inspiration  cause  an  overdose. 

Emergencies. — The  most  frequent  source  of  anesthetic  acci- 
dents arises  from  imperfect  exclusion  of  undesirable  cases,  or  if 
they  are  recognized  as  undesirable,  from  improper  preparation. 
Patients  who  have  myocarditis  or  fatty  hearts,  very  marked 
atheroma,  advanced  nephritis,  Addison's  disease,  or  status  lymph- 
aticus,  and  those  who  have  had  serious  trouble  from  anesthesia  are 
bad  risks,  and  should  be  anesthetized,  however  briefly,  only 
under  the  direst  necessity.  Those  who  are  extremely  septic  are 
likewise  bad  subjects.  On  the  contrary,  tuberculous  patients  are, 
as  a  rule,  easily  and  safely  anesthetized,  except  in  advanced  pul- 
monary cases.  In  spite  of  all  precautions  there  will  remain  a  small 
mortality  attached  to  the  administration  of  anesthetics.  The 
cases  due  to  mechnical  obstruction  of  the  air-passages  by  blood, 
mucus,  tongue,  tonsils,  and  foreign  bodies  can  be  easily  elimin- 
ated at  the  time  or  prepared  for  in  advance.  The  two  causes  to 
which  attention  is  especially  called  are  paralysis  of  the  heart  and 
of  the  muscles  of  respiration. 

In  case  the  heart  fails  to  perform  its  function,  the  anesthetic 
is  withdrawn  instantly,  the  patient  is  placed  in  an  exaggerated 
Trendelenburg  position  (except  in  the  presence  of  large  masses  in 
the  abdomen  which  by  pressure  may  further  cripple  the  heart's 
action);  stimulants  are  to  be  administered,  of  which  adrenalin 
chlorid  is  the  most  important,  and  it  should  be  given  directly 
into  a  vein  in  normal  salt  solution.  The  heart  may  be  stimulated 
into  action  by  slapping  the  chest  directly  over  the  cardiac  region, 
!>v  massage  through  the  diaphragm  in  abdominal  cases,  or  directly, 
after  doing  thoracotomy.  Experimentally  the  latter  has  proved 
to  be  a  wonderful  plan;  in  human  practice  it  has  not  so  far  been 
resorted  to  extensively. 

If  respiration  fails,  one  must  determine  instantly  whether  or  not 
it  is  due  to  obstruction;  if  it  is,  the  effort  is  continued  by  the 
patient,  but  it  is  unavailing,  and  the  obstruction  should  be  re- 
moved or  relieved  by  tracheotomy  or  intubation. 

<  Mhenvise  the  pul-e  i>  to  be  examined  immediately,  and  will 
probably  be  found  of  sufficient  volume.  The  head  is  lowered  and 
artificial  re>piration  is  done  with  the  normal  rhythm,  not  rapidly 
and  excitedly.  (  Kyiien  may  be  used,  especially  if  a  Meltzer-Auer  or 
K1>1  term's  apparatus  is  at  hand,  as  this  plan  alone  will  aerate  the 
blood  for  an  indefinite  time.  The  sphincter  ani  externus  should 
lie  dilated  or  a  lump  of  ice  inserted  into  the  rectum  and  cold 
applications  made  to  the  face.  So  long  as  the  heart  continues  to 
beat  these  efforts  should  be  continued,  but  they  often  prove 


442  PRINCIPLES    OF   SURGERY 

futile  in  cases  both  of  cardiac  and  respiratory  paralysis.  The 
faradic  battery  has  been  used  in  these  cases  of  paralysis  with 
questionable  results.  It  is  superfluous  to  add  that  the  anesthetic 
should  be  discontinued. 

There  are  certain  danger  signals  which  should  impress  the 
anesthetist  at  once,  namely,  rapidity  of  the  pulse,  especially  if  it 
occurs  suddenly;  sudden  fall  of  the  blood-pressure  in  the  absence 
of  marked  hemorrhage,  and  dilatation  of  the  pupils,  the  wider  the 
worse,  hi  complete  anesthesia;  and  they  demand  that  the  anes- 
thetic be  discontinued,  or  practically  so,  until  the  condition  can 
be  righted. 

Following  anesthesia  there  is  usually  a  period  of  more  or  less 
prolonged  nausea  and  vomiting.  This  depends  on  the  anesthetic, 
the  mode  of  its  administration,  the  quantity  consumed,  and  the 
duration.  Ether  more  uniformly  produces  nausea  and  vomiting 
than  the  other  anesthetics,  but  occasionally  they  may  follow 
chloroform  and  continue  for  several  days.  Ordinarily  the  nausea 
disappears  by  the  end  of  six  to  twelve  hours.  This  is  one  of  the 
greatest  objections  to  general  anesthesia;  and,  although  it  can 
be  reduced  to  a  minimum,  so  far  it  cannot  be  uniformly  eliminated. 
The  best  plan  for  prevention  is  proper  preparation  beforehand, 
proper  administration  by  a  skilled  anesthetist,  avoidance  of  un- 
necessary delay  in  the  operation,  and  lavage  of  the  stomach 
as  soon  as  practicable  after  the  anesthetic.  If  these  fail,  various 
drugs  are  employed  to  control  the  nausea  if  it  is  distressing,  of 
which  the  most  important  are  morphin  hypodermically,  the  ob- 
jections to  which  need  no  mention.  Chloretone  has  been  ad- 
ministered with  some  success.  The  administration  of  1-minim 
doses  of  tincture  of  iodin  hi  1  dram  of  water  every  hour  or  two 
seems  to  give  some  relief. 


CHAPTER   XXXIII 
TUMORS 

Definition. — A  tumor  is  an  autonomous  growth  consisting  of 
perverted  cells,  maintaining  itself  independently  and  at  the  sacri- 
fice of  normal  tissues,  and  functionating  incorrectly. 

Until  the  etiology  and  pathology  of  tumors  are  more  fully  under- 
stood no  correct  definition  perhaps  can  be  given.  The  term '  'tumor' ' 
formerly  embraced  many  lesions  (granulomata)  which  have  been 
removed  from  this  category  by  advances  in  our  knowledge,  which 
in  every  instance  has  limited  the  scope  of  the  word  tumor.  What 
further  restriction  may  be  established  by  future  investigations 
cannot  even  be  surmised.  The  definition  is  intended  to  distinguish 
tumors  as  a  group  from  physically  similar  masses  produced  by 
known  causes,  such  as  tuberculous  masses,  gummata,  actinomy- 
cosis,  inflammatory  masses,  and  new  tissue  formation  in  general, 
the  causation  of  all  of  which  we  know  very  definitely,  and  which 
are  derived  from  the  pre-existing  cells  in  consequence  of  the  action 
of  definite  causes.  While  clinically  and  microscopically  the  differ- 
ent uition  between  such  enlargements  is  often  difficult,  yet  their 
behavior  upon  withdrawal  or  destruction  of  their  cause  is  entirely 
different  from  that  of  tumors.  The  former  disappear  or  are  re- 
placed by  fibrous  tissue,  and  have  not  in  their  cells  the  power  to 
propagate  themselves  indefinitely  after  their  extracellular  stimu- 
lus is  gone.  But  tumors  are  made  of  cells  a  part  of  whose  nature 
is  this  perverted  tendency  to  multiply  indefinitely  and  independ- 
ently of  any  so  far  recognized  extraneous  stimulus;  in  them  it  is  in- 
herent, intracellular,  and  the  new-cell  progeny  have  the  same 
tendency  transmitted  to  them,  which  does  not  occur  in  inflamma- 
tory masses.  There  is  no  tendency  in  tumors  toward  retrogression 
and  toward  cessation  of  their  unnatural  course.  The  cells  of  in- 
flammatory masses  represent  an  effort  of  nature  to  antagonize  the 
cause,  or  the  result  which  such  antagonism  produces  on  them. 
The  cells  of  tumors  represent  only  the  aimless  multiplication  of 
cell-  whose  only  well-performed  function  is  this  very  multiplica- 
tion and  self-nutrition  in  spite  of  the  fate  of  related  tissues  of  the 
body  as  a  whole.  Tin-  .-:imr  difference  is  observed  in  hypertro- 
phies and  hyperplasias;  producing  abnormal  enlargement  of  parts 
and  organs,  the  cells  maintain  their  proper  relation  to  the  general 
economy.  In  tumors  their  behavior  is  independent  of  local  or 
general  needs  and  of  the  tissues  from  which  they  are  derived. 

443 


444  PRINCIPLES   OF   SURGERY 

Benign  and  Malignant  Tumors. — The  most  important  sub- 
division of  tumors  is  that  based  on  their  clinical  course,  namely, 
into  benign  and  malignant;  and  while  there  are  all  degrees  be- 
tween the  two,  it  is  of  the  utmost  practical  importance,  both  from 
the  standpoint  of  prognosis  and  of  treatment,  to  know  hi  which  of 
these  subdivisions  a  given  tumor  falls;  not  that  one  would  wait 
for  the  development  of  the  tumor  until  its  clinical  course  is  mani- 
fest, but  with  a  view  of  recognizing  microscopically  the  nature  of  the 
growth  in  its  early  stages  and  of  advising  its  host  accordingly. 

A  benign  tumor  is  one  that  in  and  of  itself  has  no  tendency  to 
destroy  the  life  of  the  individual.  Its  presence  in  the  tissues  does 
not  per  se  reduce  the  health  and  result  hi  emaciation  and  death. 
Death  may  result  from  a  benign  tumor,  but  when  it  does,  it  comes 
in  consequence  of  the  physical  presence  of  the  tumor,  where  the 
tumor  behaves  precisely  as  a  foreign  body  in  its  position  would,  or 
hi  consequence  of  accident  or  complication.  So  by  obstructing 
large  vessels,  the  alimentary  tract,  the  air-passages,  or  by  pres- 
sure on  the  brain  or  cord  a  benign  tumor  may  cause  death  indi- 
rectly; on  the  other  hand,  it  may  become  gangrenous  or  inflamed 
and  suppurate,  or  bleed  in  consequence  of  pathologic  change  or 
accident,  and  produce  death  indirectly,  as  would  happen  if  a 
similar  condition  were  produced  in  normal  tissues. 

A  malignant  tumor  is  one  which  hi  and  of  itself  does  produce 
death  invariably  if  allowed  to  pursue  its  course  unmolested.  It 
may  accidentally  kill  the  patient  by  its  mechanical  presence  or  by 
accident  or  complication,  and  it  is  much  more  subject  to  such 
than  benign  tumors  are;  however,  if  this  fails,  death  invariably 
results  from  the  presence  of  a  malignant  tumor  in  the  tissues; 
malignant  tumors  kill  regardless  of  the  ultimate  size  attained,  the 
small  as  certainly  as  the  large. 

It  is  necessary  for  the  student  of  tumor  pathology  to  learn  not 
only  the  difference  in  a  general  clinical  way  between  benign  and 
malignant  tumors,  but  the  essential  microscopic  difference  which 
is  the  earliest  positive  plan  of  differentiation,  and  the  only  certain 
very  early  differential  means  at  our  command. 

Rate  of  Growth. — The  rule  is  that  benign  tumors  grow  slowly, 
while  malignant  tumors  grow  rapidly.  But  the  terms  "slow"  and 
"rapid"  are  so  indefinite  that  their  significance  can  be  learned  only 
from  practical  experience.  There  are  frequent  exceptions  to  the 
rule,  for  a  malignant  tumor  may  exist  for  ten  or  more  years  and 
the  part  in  which  it  develops  be  smaller  than  normal,  while  a  be- 
nign tumor  may  reach  a  very  suspicious  size  within  a  year. 

Blood  Supply. — Benign  tumors,  except  vascular  tumors,  are 
more  poorly  supplied  with  blood-vessels  than  malignant,  but  this 
is  of  more  value  from  the  operative  standpoint  than  from  the 


TUMORS  445 

diagnostic,  and  is  of  very  great  importance  in  connection  with  the 
great  tendency  of  certain  malignant  tumors  to  be  complicated  with 
hemorrhage,  which  is  often  uncontrollable  and  may  hastily  produce 
death. 

Encapsulation. — The  capsule  of  a  tumor  is  a  white  connective- 
tissue  sheath  surrounding  it.  The  capsule  is  derived  from  the 
accumulation  of  connective  tissue  on  the  surface  of  a  tumor  as  it 
enlarges  and  from  the  proliferation  produced  by  the  growth. 
Benign  tumors  are  usually  encapsulated — i.  e.,  the  whole  tumor, 
all  of  the  tumor  cells,  constitutes  the  mass  within  the  capsule. 
Manifestly  those  benign  tumors,  such  as  warts,  which  do  not  de- 
velop in  the  midst  of  connective  tissue,  are  not  encapsulated. 
The  capsule  may  vary  in  thickness,  in  one  instance  being  definite 
and  well  developed,  in  another  extremely  attenuated.  Malignant 
tumors  are  usually  not  encapsulated;  however,  sarcomata,  especi- 
ally early  in  their  course,  may  be  definitely  encapsulated,  and  thus 
present  some  of  the  usual  signs  of  benign  tumors;  their  capsule  is 
not  a  true,  but  a  pseudocapsule;  the  difference  between  the  two 
being  that  a  true  capsule  contains  all  the  tumor  elements  within 
it,  whereas  a  pseudocapsule  may  contain  tumor  cells  in  the  sub- 
stance of  its  wall,  and  they  may  be  found  also  entirely  outside 
the  capsule,  that  is,  a  pseudocapsule  does  not  contain  all  the 
tumor  elements  within  it. 

Pain. — Pain  is  absent  from  benign  tumors  except  when  they 
involve  nerve  tissue  in  their  growth,  press  upon  nerve-endings  or 
fibers,  or  are  painful  on  account  of  accidents  or  complications. 
Malignant  tumors  are  usually  painless  until  they  have  advanced 
well  in  their  course,  and  the  physician  must  never  await  the  ap- 
pearance of  pain  as  a  diagnostic  point  or  draw  conclusions  from 
its  absence. 

Infiltration. — Infiltration  may  be  defined  as  the  growth  of  the 
tumor  into  surrounding  structures.  Benign  tumors  do  not  infil- 
trate the  cells  remaining  in  contact  with  the  tumor  and  form- 
ing a  part  of  the  tumor  mass,  which  is  definitely  delimited.  On 
tin-  contrary,  malignant  tumors  infiltrate  surrounding  tissues,  so 
that,  although  the  tumor  may  seem  to  be  definite  in  its  outlines 
and  even  encapsulated,  one  cannot  know  to  what  extent  cells 
from  the  tumor  have  grown  from  this  mass  into  the  surrounding 
ti»ues,  or  when  proce.->e-  have  projected  themselves  into  the 
lymph—paces  and  along  various  other  channels.  Thus  it  is  pos- 
sible to  understand  how  the  lumen  of  a  vein  may  be  filled  with  a 
pror.-s  which  has  extended  through  the  wall  l>y  infiltration  and 
grown  along  the  canal;  or  how  a  small  process  may  grow  out  through 
a  foramen  and  produce  a  second  nodule  directly  connected  with  Un- 
original mass,  as  potatoes  are  with  the  vine.  Infiltration  of  malig- 


446  PRINCIPLES   OF   SURGERY 

nant  tumors  causes  disintegration  and  destruction  of  the  tissues 
affected,  bone  even  being  no  exception  to  the  rule.  In  many  in- 
stances infiltration  may  be  recognized  by  the  indefinite  outlines 
of  the  tumors  or  by  their  fixation.  The  direct  growth  of  cancer 
cells  from  one  organ  into  another  in  contact  with  it  deserves  men- 
tion here. 

Mobility. — Because  of  their  encapsulation  benign  tumors  are 
movable,  which  means  that  they  are  capable  of  being  moved 
relative  to  the  tissues  which  immediately  surround  them,  and 
not  simply  that  the  organ  in  which  they  originate  can  be  moved 
in  its  relations.  When  a  benign  tumor  arises  from  a  structure, 
such  as  bone,  relative  to  which  it  cannot  be  moved,  the  relative 
mobility  of  the  surrounding  soft  parts  may  be  recognized  and 
amount  to  the  same  clinical  significance  as  if  the  tumor  were  mov- 
able hi  its  bed.  Benign  tumors,  especially  in  the  pelvis  and  ab- 
domen, may  become  fixed  and  immovable  on  account  of  adhe- 
sions to  the  parietes  and  viscera;  this,  of  course,  is  accidental, 
and  offers  no  solution  to  the  nature  of  the  tumor.  It  is  wise  if 
possible  to  elicit  a  history  which  would  determine  the  presence 
or  absence  of  such  inflammation.  Malignant  tumors  may  be 
immovable  from  their  inception;  they  may  be  movable  for  a  time 
and  become  fixed  later  by  infiltration,  or  they  may  appear  as  a 
retrograde  change  occurring  in  old  benign  tumors,  and  this  fixa- 
tion is  one  of  the  important  signs  of  such  change.  Immobility  of  a 
malignant  tumor  may  be  recognizable  only  partially,  i.  e.,  not 
in  every  direction,  as,  for  example,  is  shown  in  the  early  appearance 
of  Halstead's  sign  of  mammary  carcinoma.  Immobility  may,  in 
advanced  stages  of  infiltration,  be  so  extensive  as  to  fix  the  organ 
in  which  the  tumor  appears,  or  several  organs  may  be  fixed  im- 
movably together  and  the  whole  mass  densely  attached  to  sur- 
rounding structures.  So  the  rectum,  vagina,  uterus,  and  bladder 
may  all  be  involved  in  one  cancerous  mass  and  the  whole  at- 
tached to  the  pelvic  walls.  A  very  important  means  of  deter- 
mining mobility  of  tumors  of  the  skin  or  mucous  membrane  and  of 
tumors  which  underlie  these  membranes  is  to  attempt  to  elicit 
the  normal  gliding  of  these  membranes  over  subtegumentary 
structures;  if  this  is  absent,  it  is  interpreted  as  immobility. 

Lymph-node  Enlargement. — Benign  tumors  do  not  affect  the 
lymph-nodes  into  which  the  region  drains.  Malignant  tumors 
of  the  cancerous  type  do  produce  enlargement,  which  is  due  to  the 
presence  and  multiplication  of  cancer  cells  within  the  nodes. 
Sarcomata  occasionally  produce  lymph-node  involvement,  but 
only  in  special  cases.  It  may  become  necessary  to  distinguish 
between  enlargement  of  lymph-nodes  due  to  cancer  cells  and  that 
arising  from  infection  of  an  ulcerative  tumor  from  which  no  cells 


TUMORS  447 

have  reached  the  lymph-nodes.  This  can  be  surmised  only  in  a 
clinical  way,  the  cancerous  nodes  coming  up  slowly,  while  those  due 
to  infection  may  enlarge  in  a  very  few  days.  The  only  certain  test 
is  the  microscope,  and  in  case  of  doubt  the  patient's  welfare  de- 
mands that  such  nodes  be  treated  as  cancerous.  Manifestly,  in- 
flammation of  benign  tumors  may  cause  lymph-node  involvement. 
Metastasis. — By  metastasis  is  meant  the  escape  of  a  cell  or  a 
group  of  cells  from  a  tumor  into  the  blood-  or  lymph-vessels,  and 


Fig.  89. — Metastasis  in  lung.     Tcratoma  testis.     (X  about  J  natural  suse.) 

its  lodgment  and  development  in  some  more  or  less  remote  part 
of  the  body.  The  secondary'  tumors  thus  formed  are  called  metas- 
tases,  and  produce  the  same  cell  types  found  in  the  original  or 
primary  tumor.  Benign  tumors  do  not  metastasize;  a  few  excep- 
tions have  been  observed  apparently  in  cases  of  adenoma  and 
chondroma,  but  if  benign  tumors  ever  produce  metastases  it  is 
so  rare  an  occurrence  as  to  have  little  practical  hearing.  Malignant 
tumors  do  hahitually  produce  metastases.  Tumor  cells  escape 
into  the  blood-vessels  or  lymph-channels  and  are  carried,  in  the 


448 


PRINCIPLES   OF   SURGERY 


first  instance,  to  the  first  vessel  too  small  to  admit  their  passage, 
and,  in  the  second,  to  the  first  lymph-node,  and  there  begin  the 


Fig.  90. — Metastasis  in  stomach.    Teratoma  testis.    (X  about  5  natural  size.) 


Fig.  91. — Metastasis  in  brain.     Teratoma  testis.     (X  about  £  natural  size.) 

development  of  secondary  tumors.    It  must  not  be  concluded  that 
all  secondary  tumors  are  metastatic,  as  will  be  shown  later. 

Ulceration. — As  any  normal  structure  may  be  affected  by 
ulceration,  so  may  any  tumor,  the  benign  with  less  frequency 


TUMORS  449 

than  normal  tissue;  malignant  tumors,  especially  cancers,  with 
far  greater  frequency.  This  is  so  true  that  few  malignant  tumors, 
indeed,  situated  in  the  skin  or  mucous  membrane,  or  which  reach 
these  teguments  by  infiltration,  escape  ulceration  at  some  time 
in  their  course — some  early,  some  late. 

The  ulcers  are  of  the  chronic,  incurable  type;  no  granulations 
of  a  healthy  nature  are  seen,  and  the  surfaces  of  the  ulcers  are  cov- 
ered with  necrotic  material,  discharge  more  or  less  abundantly,  and 
emit  the  unmistakable  odor  of  decomposing  flesh.  This  odor  may, 
in  uleerutive  earcinomata,  be  quite  as  intolerable  as  that  observed 
in  the  worst  forms  of  gangrene.  It  should  be  remembered  hi 
cases  either  of  carcinoma  or  sarcoma  that  incision  into  the  tumor 
is  more  likely  to  be  followed  by  ulceration  than  by  healing;  the 
flo-rr  the  tumor  is  to  the  surface,  the  greater  this  probability. 

Hemorrhage. — In  consequence  of  two  pathologic  facts — namely, 
that  malignant  tumors  invade  and  weaken  the  walls  of  blood-vessels 
and  that  they  ulcerate — it  is  easy  to  understand  that  hemorrhage 
is  not  only  liable  to  occur  hi  cases  of  malignancy,  but  that,  having 
occurred,  it  is  more  likely  to  persist  or  to  recur  because  of  the 
unhealthy  condition  of  the  vascular  walls  and  their  consequent 
imperfect  physiologic  activity.  So  frequent  is  ulceration  and 
hemorrhage  in  cases  of  concealed  cancers  of  the  digestive  tract 
that  the  latter  is  one  of  the  most  important,  though  unfortunately 
too  late,  signs  of  this  condition  relied  on  by  the  profession.  In 
addition  to  the  hemorrhage  attendant  upon  ulceration,  sarco- 
mata frequently  bleed  into  their  own  tissues,  a  very  characteristic 
feature,  but  present  no  grave  dangers  so  long  as  the  blood  can- 
not escape.  When  hemorrhage  from  an  ulcerative  surface  occurs, 
it  may  recur  in  slight  attacks  until  emaciation  and  anemia  are 
extreme,  or  it  may  be  profuse  and  result  in  immediate  death. 
Heni gii  tumors  do  not  ulcerate  and  consequently  do  not  bleed, 
as  a  rule;  neither  are  they  subject  to  hemorrhage  into  the  tumor 
substance. 

Cachexia. — It  has  been  shown  already  that  benign  tumors  do 
not  tend  to  kill:  likewise  they  do  not  affect  the  general  health  of 
their  host.  On  the  contrary,  malignant  tumors  do  invariably 
affect  the  general  health  independently  of  their  local  complica- 
tions, although  they  may  advance  to  enormous  dimensions  occa- 
sionally without  producing  great  constitutional  impression,  pro- 
vided tiny  e-cape  ulceration,  hemorrhage,  and  infection,  which 
add  to  the  intensity  of  cachexia  and  to  the  rapidity  of  the  develop- 
ment. Cachexia  i-  manifested  l>y  pallor  or,  rather,  a  sallow  skin, 
emaciation,  and  anemia,  and  is  attended  by  weakness  and  anorexia. 

Recurrence. — When  a  benign  tumor  is  dissected  out  one  may 
be  certain  inmost  instances  that  it  is  removed  in  toto;  consequently 

29 


450 


PRINCIPLES   OF   SURGERY 


it  will  not  recur.  But,  owing  to  infiltration,  metastases,  and  the 
root-like  protrusion  of  tumor  tissues  into  the  lymph-channels 
and  similar  spaces,  one  can  never  be  absolutely  certain  of  remov- 
ing all  of  a  malignant  growth,  and  it  is  necessary  to  admit  that 
in  a  large  percentage  of  cases  even  the  most  extensive  removal 
fails  to  eradicate  the  whole  of  the  new  growth.  The  cells  left 
in  situ  continue  to  multiply,  and  after  a  time,  often  amounting  to 
several  years,  the  tumor  recurs. 

Degeneration. — The  cells  of  the  benign  tumors  are  of  a  type 
much  closer  to  normal  tissue  than  those  of  malignant  tumors, 
grow  much  less  rapidly,  and  are  much  less  subject  to  degenerative 
changes  than  the  latter.  This  fact  explains  how  it  happens  that 


Fig.  92. — Cachexia.     Osteosarcoma  of  cranium.     This  patient  died  within 
three  days  after  this  photograph  was  made. 

malignant  tumors  are  so  much  more  prone  to  ulceration  and 
disintegration. 

Microscopic  Differences. — The  above  differentiation  between 
benign  and  malignant  tumors  is,  as  has  been  stated,  clinical. 
But  it  is  necessary  to  know  the  character  of  a  tumor  long  before 
these  various  manifestations  occur,  and  the  microscope  is  resorted 
to  to  ascertain  the  facts.  Yet  the  question  arises  here,  namely, 
Just  what  is  the  essential  microscopic  evidence  which  constitutes 
the  proof  that  a  tumor  is  malignant?  It  must  be  stated  here  that, 
since  it  is  impossible  practically  for  the  pathologist  to  examine 
carefully  every  part  of  a  specimen  submitted,  he  may  be  un- 
fortunate enough  to  find  no  evidence  of  malignancy  in  the  section 


TUMORS  451 

examined,  while  another,  near  or  remote,  would  show  unmistak- 
able proof  of  it.  For  this  reason  the  pathologist  should,  if  pos- 
sible, have  the  whole  tumor  submitted  for  a  choice  of  sections, 
or  the  section  submitted  should  be  taken  from  the  most  sus- 
picious (clinically)  portion,  namely,  the  most  rapidly  growing 
portion.  There  can  be  no  question  that  every  specimen  of  the 
least  uncertainty  should  be  submitted  to  microscopic  examination. 
In  normal  tissues  cells  of  certain  function  are  found  only  in  cer- 
tain relations  to  the  tissues  about  them.  Hence,  the  epithelium 
in  various  parts  of  the  body  is  found  to  lie  on  a  connective-tissue 
substratum.  In  benign  tumors,  although  there  may  be  much  dis- 
turbance of  structure  in  a  gross  or  microscopic  way,  yet  this  one 
relation  remains  undisturbed,  and  the  epithelial  cells  of  the  tumor 
are  found  always  on  the  right  side  of  the  connective-tissue  sup- 
port and  in  proper  relation  to  it.  But  hi  malignant  tumors  the 
so-called  "insane  cells"  show  evidence  of  penetration  of  their  sup- 
porting tissue  in  all  stages,  from  the  slightest  dip  below  the  proper 
level  to  invasion  of  the  membrane  and  into  the  tissues  beyond. 
The  power  a  cell  has  to  invade  tissues  contrary  to  its  normal 
histologic  and  functional  relationship  establishes  its  malignancy. 
Malignancy  cannot  be  safely  diagnosed  as  suspicious  by  the 
pathologist.  If  the  tumor  is  malignant,  it  should  show  the  proof. 
If  it  is  only  suspicious  as  yet,  it  has  surely  not  reached  the  stage 
where  the  same  operation  should  be  done  as  hi  cases  of  certain 
malignancy.  Welch's  experience  with  uncertain  cases  has  led  him 
to  the  conclusion  that  they  are  almost  invariably  benign.  The 
nearer  the  cells  are  in  their  resemblance  to  the  embryonic  type, 
the  meat (i-  the  probability  of  malignancy. 

The  Origin  of  Tumors. — There  are  two  antagonistic  theories 
as  to  the  source  of  tumors.  The  cellular  theory  is  accepted  by  its 
supporters  as  an  explanation  of  the  entire  list,  while  those  who 
advocate  the  parisitic  theory  explain  only  certain  tumors  by  it, 
leaving  the  remainder  untouched  (see  Etiology  of  Cancer). 

The  cellular  theory,  usually  accredited  to  Cohnheim,  proposes 
an  explanation  of  the  origin  of  tumors  as  follows:  It  is  supposed 
that  a  larger  number  of  cells  is  produced  hi  the  early  subdivisions 
of  the  ovum  both  before  and  after  its  formation  of  epiblast, 
mesohlast.  and  hypoblast  than  is  necessary  for  the  future  develop- 
ment of  the  embryo  into  a  normal  child,  and  that  these  cells  cease 
to  multiply  and  remain  quiescent  alongside  of  the  other  multiply- 
ing cells  and  are  enveloped  by  tin-in.  Those  cells  which  cease 
to  develop  further  are  known  as  "cell  rests."  As  the  tissues  reach 
a  further  stage  of  development  toward  the  normal  fetus,  when  the 
cells  have  specialized  for  the  formation  of  various  histologic  tis- 
sues, still  other  more  highly  developed,  more  specialized  cells  are 


452  PRINCIPLES   OF   SURGERY 

converted  into  "cell  rests."  From  these  cell  rests  tumors  are  sup- 
posed to  originate,  due  to  the  rest  cells  taking  on,  from  some  un- 
known cause,  a  second  growth,  so  to  speak,  in  which  their  power 
to  multiply  is  re-established,  and  that  without  restriction  and  out 
of  all  relation  to  local  or  general  demands  of  the  body,  and  without 
the  power  to  advance  beyond  the  stage  they  had  reached  when 
they  became  rests.  To  this  Nicholas  Senn  added  the  further 
item  that  not  only  cell  rests  may  produce  tumors,  but  they  may 
originate  from  imperfectly  developed  (young)  cells  which  are 
formed  in  the  course  of  the  healing  or  regenerative  process.  Hence, 
there  are  tumors  of  the  early  embryonic  cell  type,  which  are  known 
as  malignant  tumors,  and  various  tumors  of  more  or  less  fully 
developed  cells,  which  conform  histologically  to  the  normal  varie- 
ties of  tissue  found  in  the  body,  and  their  tissues  resemble  the 
normal  so  closely  that  one  would  often  be  at  a  loss  to  differentiate 
the  one  from  the  other.  Furthermore,  the  classification  of  tumors 
can  be  made  by  considering  the  embryonic  layers  of  tissue,  and 
subdividing  those  tumors  falling  under  the  respective  types  in 
accordance  with  the  histologic  structure  of  the  tissue  found. 
Homologous  tumors  are  those  forming  in  tissues  of  their  own 
type;  heterologous  tumors  form  in  tissue  histologically  different. 

In  this  connection  it  is  necessary  to  impress  that  tumors  which 
originate  from  the  cells  of  one  of  the  three  embryonic  layers  never 
are  converted  into  those  which  originate  from  cells  derived  from 
another  layer.  Hence,  mesoblastic  tumors  are  characterized  by 
some  variety  of  mesoblastic  cells;  if  benign,  they  may  become 
malignant,  but  if  they  do  it  is  certain  that  a  mesoblastic  malig- 
nant tumor  will  result;  the  same  is  true  of  epiblastic  and  hypo- 
blastic  tumors. 

Classification  of  Tumors. — 

I.  Mesoblastic  (Connective-tissue)  Tumors: 

A.  Benign.  B.  Malignant. 

1.  Chondroma, }  1.  Sarcoma. 

2.  Osteoma,  2.  Endothelioma. 

3.  Lipoma,         ^  Lower  forms. 

4.  Myxoma, 

5.  Fibroma,       J 

6.  Myoma,  ^1 

7.  Angeioma,  I  TT-  i.     r 

8.  Lymphangeioma,  f  Hl8her  forms' 

9.  Neuroma, 

II.  Epiblastic  and  Hypoblastic  Tumors: 

A.  Benign.  B.  Malignant. 

1.  Papilloma  (Tegumentary  Cells).      1.  Epithelioma  (Tegumentary  Cells). 

2.  Adenoma  (Secreting  Cells).  2.  Carcinoma  (Functionating  Cells). 

III.  Mixed  Tumors: 

A.  Teratoma. 


CHAPTER    XXXIV 
CHONDROMA 

Definition. — The  essential  element  of  this  tumor  is  cartilage. 

Classification. — Chondromata  are  subdivided  into  ecchondro- 
matu,  or  ecchondroses,  enchondromata,  and  chondromata  of  soft 
tissues.  Ecchondromata  originate  from  normal  cartilage  and  ap- 
pear as  outgrowths  from  it,  as  small  and  usually  unimportant 
masses;  they  may  be  ecchondroma  simplex,  which  remains  per- 


1  i'_r.  '.>:{.— Smull  incscntcric  chondroma. 

manently  in  tin-  cartilaginous  state,  or  ecchondroma  ossificans, 
which  -ho\v-  a  <iivater  <>r  -mailer  degree  of  o— ideation. 

EncliontlroiiKitu  an-  derive* I  from  cartilaginous  rests  in  the  sub- 
stance of  normal  bone,  but  always  in  bone  derived  originally  from 
cartilage;  they  <lo  not  ajipear  in  bones  which  fornunl  in  membranes, 
such  as  the  cranial  bones.  They  may  be  peripheral,  forming  at  the 


454  PRINCIPLES   OF   SURGERY 

surface  of  the  bone,  or  central,  forming  within  the  substance  of  the 
bone. 

Chondroma  fractures  is  a  cartilaginous  outgrowth  from  the  site 
of  a  recent  fracture  into  the  surrounding  soft  parts. 

Chondromata  appear  also  in  the  soft  parts,  and  are  conse- 
quently heterologous  tumors,  all  of  the  above  being  homologous. 

Etiology. — Most  chondromata  originate  without  discoverable 
cause,  presumably  from  cartilaginous  rests  at  their  point  of  origin. 
It  is  interesting  to  note  that  heterologous  chondromata  are  found 
almost  invariably  in  structures  that  lie  hi  close  anatomic  relation 


Fig.  94. — Mesenteric  chondroma  the  size  of  a  large  orange. 

to  bone  or  cartilage,  or  that  lie  during  the  fetal  state  in  such  rela- 
tion— e.  g.,  the  testicle — and  Cohnheim  and  his  followers  explain  in 
this  way  the  source  of  cartilage  cells  in  the  soft  structures.  Trau- 
matism  may  serve  as  a  cause,  as  was  indicated  above  by  the  term 
"chondroma  fracturae,"  especially  if  the  injury  is  received  during 
the  period  of  growth;  cartilage  rests  are  also  produced  in  rickets. 
Structure. — The  matrix  of  chondromata  is  usually  hyaline 
cartilage,  although  fibrous  or  elastic  cartilage  is  sometimes  seen. 
The  cells  are  of  irregular  shape  and  have  no  definite  arrangement. 
The  blood-supply  of  the  tumor  comes  through  the  surrounding 


CHONDROMA 


455 


perichondral  membrane  and  the  connective-tissue  septa  lying 
between  the  nodules.  The  tumor  is  usually  surrounded  by  a 
definite  perichondral  capsule,  but  this  is  by  no  means  constant;  it 
is  oftener  wanting  in  the  soft  tumors.  Chondromata  are  usually 
of  irregularly  nodulated  form,  and  the  nodules  do  not  contain 
blood-vessels  or  connective  tissue. 

Sites  of  Formation. — Ecchondromata  form  in  connection  with 
normal  cartilage,  especially  in  the  larynx,  the  ribs  of  old  people, 
and  at  the  clivus  Blumanbachii. 

Enchondromata  appear  in  connection  with  the  diaphyses  of 
the  smaller  long  bones,  particularly  the  metacarpals,  metatarsals, 


Fij?.  95.— Chondroma.     (X  about  100.) 

and  the  phalanges.  They  are  also  found  less  frequently  in  the 
larger  long  bones,  especially  the  femur,  and  in  the  irregular  bones, 
of  which  the  most  important  are  the  ossa  innominata  and  the 
scapulae. 

The  heterologous  tumors  are  observed  chiefly  in  the  mammary 
gland,  the  testicle,  the  ovaries,  the  parotid  glands,  the  lungs,  and 
the  neck  (branchiogenic  chondroma).  They  are  also  seen  in  the 
fascia  (See  Fig.  96.) 

Diagnosis. — fhondromata  van-  in  size  from  very  minute 
masses  to  enormous  growths  larger  than  a  man's  head,  grow 
slowly,  and  are  surrounded  by  structures  which  are  movable  in 


456  PRINCIPLES   OF   SURGERY 

• 

relation  to  them,  except  when  situated  centrally  in  bone.  They 
are  nodular  and  hard,  as  a  rule,  although  elasticity  may  be  elicited 
in  them  after  reaching  a  moderate  size,  which  distinguishes  them 
from  bone.  The  surface  of  large  chondromata,  especially  in  old 
tumors,  often  show  soft  spots,  due  to  degeneration.  Their  prefer- 
ence for  the  osseous  system,  their  development  at  the  ends  of  the 
small  long  bones,  their  frequent  appearance  on  the  hands  and 
feet  simultaneously  and  in  great  numbers,  so  that  several  fingers 


Fig.  96. — Heterologous  chondroma  over  right  scapula. 

and  toes  may  be  affected,  and  the  deformity  resulting  therefrom, 
together  with  the  loss  of  function,  renders  their  diagnosis  easy. 
The  diagnosis  may  be  further  cleared  up  by  puncturing  the  tumor 
with  a  sharp  needle,  which  can  be  forced  into  the  substance  of  the 
tumor,  except  in  the  central  enchondromata,  and  cannot  be 
forced  into  osseous  tumors.  A  skiagraph  will  also  show  a  differ- 
ence between  the  shadow  of  cartilage  and  bone  tumors.  In  the 
softer  varieties  it  may  be  difficult  or  impossible  to  differentiate 


CHONDROMA  457 

chondroma  from  sarcoma,  especially  if  regional  or  remote  metas- 
tases  have  occurred,  and  differentiation  is  of  least  necessity  here, 
as  the  soft  ones  are  especially  liable  to  become  malignant. 

Variations. — Chondromata  sometimes  appear  as  mixed  tumors, 
the  more  common  being  osteochondroma,  fibrochondroma,  myxo- 
chondroma,  angiochondroma,  and  chondrosarcoma. 

Pathologic  Changes. — Chondromata  are  especially  liable  to 
certain  regressive  changes,  namely,  myxomatous  degeneration 
and  cyst  formation;  they  also  become  calcified  or  ossified;  in  the 
latter  instance  they  can  be  distinguished  from  osteoma  by  the 
presence  of  a  thin  layer  of  cartilage  covering  the  surface  of  the 


Fie.  !i7.  — Hftcrnlusiuits  clininlroiiia  over  right  scapula  after  removal  and  sec- 
tion. 

tumor.    Out  nil  chondromata  occasionally  are  covered  by  a  bony 

shell.  They  may  become  snreomatous  after  existing  a  long  time 
a-  l>enii:n  tumor-,  and  •  •ceasionally  produce  metastases  and  in- 
filtrate surrounding  tissues  as  sarcoma  does,  without  conforming 
to  the  latter  type  in  other  n-sprcts.  Rupture  of  the  cysts,  ulcera- 
tion.  infection,  and  putrefactive  decomposition  may  occur. 

Prognosis. — The  outlook  in  cases  of  chondroma  is  good. 
They  produce  more  or  less  deformity,  and.  when  situated  in  the 
region  of  an  articulation,  are  likely  to  limit  or  destroy  its  function. 
Of  multiple  chondromata.  tho-e  which  grow  most  rapidly  should 


458  PRINCIPLES   OF   SURGERY 

be  considered  the  most  unfavorable.    If  they  assume  accelerated 
growth  after  a  time  it  is  an  indication  of  malignancy. 

Treatment. — Chondromata  should  be  removed,  if  removal  is 
possible  without  mutilation,  unless  they  are  so  situated  as  to 
render  the  operation  hazardous.  Slowly  growing  tumors  may 
usually  be  left  in  situ  without  great  danger,  but  they  should  be 
observed  occasionally  by  a  competent  physician,  and  the  patient 
should  be  warned  of  the  possibility  of  malignant  change.  Always, 
if  possible,  they  should  be  removed  by  enucleation,  sparing  the 
surrounding  bone  and  periosteum.  When  the  bone  has  been 
rendered  useless,  when  there  are  positive  signs  of  malignancy,  and 
when  recurrence  takes  place  after  conservative  procedures,  resec- 
tion or  amputation  should  be  practised. 


CHAPTER   XXXV 
OSTEOMA 

Definition. — An  osteoma  is  a  benign  tumor  whose  essential 
structure  is  made  up  of  bone  tissue. 

Classification. — Exostoses  are  bony  outgrowths  from  bone. 
They  are  called  exostoses  when  they  arise  in  the  medullary  spaces 
of  spongy  bone. 

Osteomata  are,  in  accordance  with  their  structure,  classified 
into  osteoma  durum  or  eburnum  (ivory  or  eburnated),  osteoma 
spongiosum  (spongy  or  cancellated),  and  osteoma  medullare 
(medullary). 

Osteoma  fractures  is  an  osseous  tumor  arising  at  the  site  of  a 
fracture. 

Etiology. — Beyond  the  influence  of  trauma  and  prolonged 
irritation  nothing  is  known  of  their  origin.  They  are  frequently 
hereditary.  They  are  derived  either  from  cartilage  or  from 
periosteum.  In  the  former  case  they  form  a  subperiosteal  tumor 
immovably  attached  to  the  underlying  bone. 

Structure. — The  structure  of  eburnated  exostoses  is  exceed- 
ingly dense  and  ivory-like,  so  hard  that  they  can  frequently  not 
be  cut  with  the  best  chisels;  there  are  no  marrow  spaces,  or  but 
insignificant  ones,  no  vessels,  nothing  but  solid  bone.  In  the 
spongy  variety  the  bone-tissue  and  marrow  spaces  are  both 
present,  as  in  cancellous  bone,  from  which  it  cannot  be  distin- 
Kui.-hed  on  section.  In  the  medullary  type  the  bony  substance 
is  still  further  diminished  and  the  soft  tissue  is  much  in  excess. 

Sites  of  Formation. — The  majority  of  osteomata  form  either 
in  direct  connection  with  the  skeleton  or  in  close  proximity  to  it. 
Heterologous  osteomata  are  infrequent.  The  long  bones  at  the 
level  of  the  epiphyses  and  at  the  insertion  of  large  muscles  are 
favorite  sites.  The  bones  and  sinuses  of  the  face  and  cranium  are 
common  sites.  Osteoma  durum  is  especially  frequent  on  the  flat 
bones  of  the  skull.  Subungual  osteoma  develops  as  a  round,  painful 
nodule  under  the  great  toe-nail.  Osteomata  develop  from  the 
lower  jaw,  upper  jaw,  and  the  ethmoid,  occasionally  protruding 
into  the  orbit  or  even  from  it.  Osteoma  fracturae  (callus  luxurians) 
develops  at  the  site  of  fractures  and,  unlike  excessive  callus,  does 
not  disappear  later.  Heterologous  osteomata  are  found  in  the 

459 


460  PRINCIPLES   OF   SURGERY 

muscles  and  tendons,  in  the  brain  and  in  the  meninges,  in  the 
lungs,  trachea,  choroid,  and  sclera. 

Diagnosis. — The  presence  of  a  slow-growing,  bony-hard  tumor 
in  connection  with  the  skeleton  suggests  osteoma.  It  is  painless 
and  the  tissues  are  movable  over  it.  The  surface  may  be  smooth  or 
nodulated,  and  the  tumor  may  be  pedunculated  or  sessile.  They 
rarely  attain  the  size  of  a  fist.  They  do  not  soften,  as  chondromata 
sometimes  do,  cast  a  denser  shadow  in  the  skiagraph,  and  cannot  be 
punctured  with  a  needle.  Occasionally  a  periosteal  osteoma  is 


k 

Fig.  98. — Skiagraph  of  osteoma  of  second  and  third  metatarsals. 

movable  relative  to  the  bone.  Inflammatory  enlargements  give  a 
history  of  inflammation  and  pain  and  are  tender  upon  pressure. 
Myositis  ossificans  can  be  distinguished  by  the  history  of  trauma 
or  inflammation,  its  development  in  muscles,  usually  the  deltoid, 
adductor  magnus,  and  quadriceps,  and  the  presence  of  intact 
periosteum  covering  the  underlying  bone  as  shown  by  skiagrams. 
The  general  or  progressive  form  of  myositis  ossificans  is  slower  and 
more  widely  distributed  and  of  unknown  cause. 

Varieties. — Osteomata  are  not  admixed  with  other  types  of 
tumor  tissue,  except  in  cases  where  soft  tumors  undergo  ossifica- 


OSTEOMA  461 

tion.  They  are  almost  uniformly  made  up  of  bone,  and  conform 
to  one  of  the  types  given  above. 

Pathologic  Changes. — Pedunculated  osteomata  lying  hi  cavi- 
ties occasionally  lose  their  vitality,  due  to  infection  or  necrosis 
of  the  pedicle,  and  are  called  dead  osteomata.  Other  than  the 
changes  due  to  infection  and  the  rare  possibility  of  sarcomatous 
retrogression,  they  are  not  liable  to  pathologic  changes.  No 
changes  occur  in  osteoma  eburnum. 

Prognosis. — Osteomata  are  among  the  most  benign  tumors. 
Their  location  hi  the  pelvis  of  females  may  cause  difficult  or  im- 
possible delivery  of  the  fetus,  or,  within  the  cranial  cavity,  they 
may  produce  fatal  pressure. 

Treatment. — Unless  they  cause  serious  symptoms  or  produce 
serious  deformity  they  may  be  left  alone.  They  are  often  so 
situated  as  to  render  their  removal  impracticable.  The  ivory 
type  can  be  removed  only  with  the  greatest  difficulty,  unless  they 
are  removed  by  excising  the  segment  of  bone  containing  them. 
Pfilunculated  tumors  should  be  cut  away  at  the  base  of  the 
pedicle. 


CHAPTER   XXXVI 
MYXOMA 

Definition. — This  is  a  tumor  whose  essential  structure  is  con- 
nective-tissue cells  lying  in  a  matrix  of  mucin.  This  tissue  is  found 
normally  only  in  the  umbilical  cord  of  the  fetus,  in  the  vitreous 
humor  of  the  eye,  and  in  the  degenerative  changes  occurring  in 
the  old.  It  is  abundant  in  the  developmental  life  of  the  fetus, 
and  is  the  antecedent  of  connective  and  adipose  tissue.  This  tumor, 
therefore,  is  closely  allied  to  fibromata  and  lipomata. 

Classification. — Myxomata  do  not  occur  in  pure  form,  there 
being  always  an  admixture  of  other  tissue  elements,  which  will 
be  discussed  under  varieties.  Clinically,  they  are  soft  or  hard, 
dependent  upon  the  quantity  of  mucin,  cells,  and  connective 
tissue.  In  connection  with  the  mucous  membrane  they  are  spoken 
of  as  polyps.  The  mixed  myxomata  are  distinguished  from  other 
tumors  suffering  myxomatous  degeneration.  For  example,  a  tu- 
mor consisting  of  an  admixture  of  fatty  tumor  tissue  with  myx- 
oma  is  called  lipomyxoma  or  myxolipoma,  while  a  lipoma  under- 
going myxomatous  degeneration  is  called  lipoma  myxomatodes. 

Etiology. — Nothing  is  known  of  the  etiology  more  than  the 
embryonic  theory  of  Cohnheim. 

Structure. — The  structure  of  myxomata  is  the  presence  of 
cells  in  an  intercellular  substance  (matrix)  of  mucin,  which  coagu- 
lates in  alcohol  and  shows  the  acetic  acid  reaction  (microscopically). 
The  cells  may  be  round,  spindle,  or  multipolar.  In  the  latter  in- 
stance the  processes  may  be  extremely  long,  and  seem  to  anasto- 
mose with  those  from  other  cells.  Giant  cells  are  occasionally 
observed.  The  tumor  is  surrounded  by  a  capsule,  from  which 
blood-vessels  ramify  in  varying  abundance  throughout  the  tumor. 

Sites  of  Formation. — From  what  has  been  said  above,  it  may 
be  easily  understood  that  myxomata  may  originate  in  any  tissue 
of  the  connective  or  adipose  type  or  in  mucous  membrane.  How- 
ever, certain  sites  are  marked  by  especial  predilection.  Myxo- 
mata occur  in  the  nose  (nasal  polypi)  with  very  great  frequency, 
and  occasionally  in  the  uterine  canal.  In  the  connective  and  adi- 
pose tissues  myxomata  are  found  most  frequently  in  the  thigh. 
The  cheeks,  particularly  at  the  angle  of  the  jaw,  the  hand,  the 
back,  the  breast,  the  labium  majus,  and  the  scrotum  are  favorite 
sites.  They  are  seen  in  the  meninges,  the  brain,  and  the  nerves. 

462 


MYXOMA 


463 


In  the  nerves  they  originate  in  the  glia,  separate  the  nerve-fibers, 
and  are  spindle  shaped.  Sometimes  they  have"  been  seen  in  the 
placenta  and  occasionally  in  the  navel. 

Diagnosis. — Myxomata  are  slow-growing,  encapsulated,  mov- 
able tumors.  They  occur  in  the  young  and  middle  aged  usually, 
but  may  be  congenital.  Many  are  seen  which  do  not  conform  to 
this  statement,  owing  to  the  fact  that  they  contain  sarcomatous 
elements.  The  superficial  tumors  arising  from  nasal  and  uterine 
mucosa  are  very  frequently  pedunculated,  a  feature  that  facili- 
tates their  removal  from  such  cavities.  Myxomata  are  translu- 
cent and  are  soft,  resembling  lipomata  or  even  cysts  in  this  respect. 


:.-'.; 
„./...,.       ,-  „•» .,  j( 

• 

«   •  •   ..  •   j\7  • 


Fig.  99. — Myxoma.     (Microphotograph  X  about  100.) 

They  may  be  fluctuant  or  pseudofluctuant.  They  are  usually 
small,  although  instances  of  individual  tumors  the  size  of  a  fist 
or  even  of  a  cocoanut  are  reported.  They  are  usually  roundish 
and  flattened  or  elongated  by  the  environing  tissues.  The  surface 
of  small  tumors  is  smooth,  but  the  larger  ones  tend  to  have  nodular 
surfaces.  They  arc  not  painful,  but,  by  virtue  of  their  frequent  de- 
velopment in  the  nose,  they  cause  distress  by  obstruction,  and 
deformity,  if  large,  and  in  the  uterine  cervix  they  may  cause 
pain  and  hemorrhage.  In  the  nasal  cavity  they  are  often  multiple. 
Variations. — This  tumor  is  probably  not  found  in  the  pure  type. 
It  is  frequently  mixed  with  fibrous  tissue,  and  this  is  the  cause  of 


464  PRINCIPLES   OF   SURGERY 

the  increased  density  in  hard  polyps,  which  are  more  frequently 
sessile  than  the  softer  ones,  and,  it  is  said,  more  likely  to  recur 
and  become  malignant  after  incomplete  removal.  They  also  ap- 
pear as  myxolipoma,  myxochondroma,  and  angiomyxoma  or 
myxoma  telangiectaticum.  Myxosarcoma  is  quite  a  frequent  form 
of  malignancy,  independently  of  secondary  changes  arising  in 
either  tumor. 

Pathologic  Changes. — Cystic  degeneration  (myxoma  cysticum) 
sometimes  occurs,  and  the  assumption  of  a  malignant  course  is  very 
common;  so  true  is  this,  that  Lexer  discusses  myxoma  under  the 
general  subject  of  sarcoma.  Ulceration  and  hemorrhage  occa- 
sionally are  observed  in  myxomata  of  the  mucous  membrane. 

Prognosis. — Encapsulated  myxomata  are  benign  and  may  be 
removed  without  danger  of  recurrence.  Care  should  be  taken, 
however,  to  remove  all  the  tumor  tissue,  a  difficult  matter  in  sessile 
hard  myxomata  arising  far  back  in  the  nose  or  from  the  base  of 
the  skull.  The  tumor  returns  either  as  it  was  or  becomes  malig- 
nant. 

Treatment. — Thorough  removal  by  excision  or  by  the  snare. 
Aside  from  any  danger  the  tumor  may  possess,  polypi  should  be 
removed  as  early  as  possible  after  their  presence  is  determined, 
for,  if  left  in  the  nose,  they  cause  obstruction  to  nasal  breathing, 
and,  if  they  attain  too  large  a  size  to  be  removed  through  the 
anterior  nares,  require  the  making  of  an  incision  through  the  face 
or  palate.  In  angiomyxomata  dangerous  or  fatal  hemorrhage 
may  attend  incomplete  removal,  so  that  in  these  cases  the  opera- 
tion should  not  be  looked  upon  lightly. 


CHAPTER    XXXVII 
FIBROMATA    (FIBROIDS) 

Definition. — This  tumor  has  as  its  essential  structure  some  form 
of  fibrous  connective  tissue. 

Classification. — The  term  "fibroma,"  or  "fibroid  tumor,"  has 
been  employed  very  extensively  to  cover  a  number  of  tumors 
which  are  not  fibromata,  such  as  the  so-called  fibroid  tumors  of 
the  uterus,  and  the  present  classification  is  made  to  embrace  patho- 
logic forms  that  hi  all  probability  are  not  tumors  at  all.  They  are 


I  ig.  100. — Fibroma  of  skin.     (Microphotograph  X  about  50.) 

given  in  this  connection  for  want  of  a  more  definite  understanding 

of  their  true  nature.  Fibromata  are,  as  a  class,  subdivisible  into 
fibroma  durum  (desmoid)  and  fibroma  molluscuni.  There  are  all 
degrees  of  density  between  these  two. 

The  subdivisions  which  will  be  discussed  in  this  chapter  are 
moles    (soft    warts),    fibroma    molluscum,    keloids,    elephantiasis 
nervorum  (lohulated  elephantiasis),  von  Recklinghausen's  disease 
3d  465 


466  PRINCIPLES   OF   SURGERY 

(neurofibromatosis),  painful  subcutaneous  tubercle,  epulis  and 
fibromata  of  the  deeper  structures,  fascia,  periosteum,  and  ap- 
oneuroses. 

Structure. — The  gross  appearance  of  fibroma  is  that  of  white 
fibrous  tissue.  It  may  be  either  hard  or  soft.  The  tumor  tends 
to  be  round  and  tabulated,  the  lobules  being  sometimes  attached 
to  the  main  tumor  by  pedicles.  The  cut  surface  is  white  and 
glistening,  and  yields  no  juice  on  scraping.  The  tumor  is  dis- 
tinctly encapsulated.  To  the  naked  eye  the  cut  surface  may  show 
the  disposition  of  the  fibers,  which  may  run  with  fair  regularity. 


° 


Fig.  101. — Intercanalicular  fibroma  of  breast.    (Microphotograph  X  about  50.) 

be  extremely  irregular,  or  arranged  in  whorls  around  the  blood- 
vessels. 

Microscopically,  the  essential  element  is  fibrous  tissue,  with 
its  cells  and  the  nourishing  blood-vessels. 

Sites  of  Formation. — The  skin  is  by  far  the  most  frequent  site 
of  development  for  fibromata.  They  occasionally  form  on  the 
mucous  membrane,  as  that  of  the  nose.  The  connective  tissue  hi 
any  part  of  the  body  may  serve  as  a  starting  point,  the  fasciae 
and  aponeuroses  of  the  abdominal  muscles  being  favorite  sites. 

The  periosteum  of  the  lower  jaw,  of  the  upper  jaw,  and  that  of 
the  base  of  the  skull  furnish  the  greater  number  of  periosteal 
fibroids.  They  are  especially  apt  to  develop  from  the  muco- 


FIBROMATA    (FIBROIDS) 


467 


periosteum  of  the  lower  jaw.    The  peripheral  nerves  are  frequently 
affected  by  the  growth  of  fibroids. 

Diagnosis. — Fibroid  tumors  possess  the  usual  characteristics 
of  benign  tumors.  They  are  usually  hard,  except  in  fibroma  mol- 
luscum,  and  movable,  unless  limited  by  the  structure  in  which 
they  originate;  even  then  the  surrounding  tissues  can  usually  be 
moved  in  relation  to  them.  The  smaller  tumors  are  round  and 
usually  smooth,  but  as  they  grow  in  size  they  tend  to  become 


fibroid. 


nodulated.    They  may  reach  an  enormous  size;  on  the  other  hand, 
many  of  them  attain  a  moderate  size  and  cease  to  grow. 

Variations. — Fibrous  tissue  plays  an  important  part  in  the  con- 
stitution of  many  tumors,  whether  epiblastic,  hypoblastic,  or 
mesnMastic.  If  such  tumors,  therefore,  contain  an  excess  of  this 
ti— uc  they  are  named  by  prHixini:  the  name  fibro- to  the  name 
of  the  other  tissue.  A  very  common  form  of  mixed  tumor  is  fibro- 
myoma  of  the  uterus.  Owing  to  the  relatively  great  benignity  of 


468 


PRINCIPLES    OF   SURGERY 


fibrous  tissue  tumors,  the  other  element  usually  determines 
largely  the  nature  of  the  tumor.  Fibroma  lymphangiectaticum 
possesses  the  elements  of  lymphangiectasis  plus  fibromatous 
tissue.  Likewise,  fibroma  telangiectaticum  and  fibroma  caver- 
nosum  are  terms  used  to  represent  mixed  forms  of  fibroma  with 
angioma  and  cavernous  angioma. 

Pathologic  Changes. — Fibromata  in  general  are  not  especially 
subject  to  harmful  changes.  In  limited  cavities,  where  subject  to 
considerable  pressure,  they  are  more  liable  to  infection,  inflamma- 
tion, and  ulceration,  which  may  be  attended  with  severe  hemor- 


Fig.  103. — Fibroid  tumor  of  the  uterus. 

rhage.  This  is  especially  true  of  fibromatous  polypi  of  the  naso- 
pharynx, and  may  occur  in  subcutaneous  fibroids  of  large  size. 
They,  especially  if  submucous,  may  undergo  myxomatous  de- 
generation, and  sometimes  cystic  degeneration.  These  changes 
cause  softening  of  the  mass  and  fluctuation.  Calcareous  degenera- 
tion may  be  found  over  the  tumor  surface,  or  at  points  throughout 
its  substance,  or  involves  the  whole  volume  of  small  tumors. 
Naturally  this  change  precludes  the  possibility  of  further  growth 
of  the  affected  tissues.  If  they  originate  from  the  periosteum, 
they  often  show  some  degree  of  ossification.  Sarcoma  does  not 


FIBROMATA    (FIBROIDS) 


4(51) 


Fig.  104. — Fibroma  of  ovary. 


Fig.  10"). — Rrtrnprritnnral  fihroi'l. 


470  PRINCIPLES   OF   SURGERY 

frequently  build  upon  fibromata  in  general,  but  one  type  of 
fibroids  deserves  especial  mention  in  this  connection,  namely, 
pigmented  moles,  which  more  frequently  than  any  other  benign 
tumor  become  sarcomatous,  particularly  if  irritated  or  injured. 


Fig.  106. — Large  submucous  fibroid  of  uterus.     This  tumor  apparently  caused 
no  menstrual  disturbance. 

Prognosis. — The  life  of  the  individual  is  rarely  lost  in  conse- 
quence of  fibromata.  They  can  be  removed  in  almost  every  in- 
stance with  positive  assurance  that  no  harm  will  result. 

Treatment. — The  only  treatment  is  removal. 

SPECIAL  FORMS  OF  FIBROMATA 

Moles,  Soft  Warts. — These  are  by  far  the  most  frequent  of  the 
skin  fibromata.  They  are  frequently  pigmented,  varying  hi  color 
from  a  slight  brown  to  black.  They  are  "usually  congenital  and 
grow,  as  a  rule,  to  their  maximum  size  by  the  time  of  puberty,  al- 
though they  may  increase  hi  size  after  this  age.  They  frequently 
are  multiple,  occasionally  scores  or  even  hundreds  being  observed 
on  a  single  individual.  They  may  be  pedunculated  or  sessile,  and 
only  slightly  elevated  or  notably  so,  and  soft  and  velvety  to  the 
touch.  They  may  be  found  on  any  surface  of  the  body  except  the 
palms  and  soles,  but  have  an  unquestionable  predilection,  especi- 
ally in  individuals  who  have  only  one  or  a  few  of  them,  for  the  face, 
neck,  scalp,  chest,  and  shoulders.  They  vary  in  size  from  almost 
invisible  specks  to  the  size  of  a  walnut.  They  may  be  flat  and 
cover  an  area  as  large  as  a  silver  dollar  or  more.  The  pigmented 
moles  are  covered  frequently  with  dark  or  black  stiff  hairs,  and 
possess  an  excessive  number  of  cutaneous  glands  and  a  thicker 
epithelial  coat  than  the  surrounding  skin.  The  surface  of  these 


FIBROMA  (FIBROIDS) 


471 


Fig.  107.— Mole.     (Microphotograph;  X  about  100.) 


Fig.  las.— Mole.     Same  as  Fig.  107.     (MirrophotoRraph;  X  about  100.) 


472  PRINCIPLES   OF   SURGERY 

tumors  is  more  or  less  irregular,  roughened,  and  wrinkled,  and 
may  present  the  appearance  of  a  berry.  Moles  are  more  likely  to 
undergo  malignant  change  than  any  other  class  of  benign  tumors. 
They  usually  become  sarcomatous,  occasionally  carcinomatous, 
and  in  either  instance  may  produce  a  pigmented  tumor,  which 
adds  to  the  malignancy. 

The  question  frequently  arises,  What  shall  be  done  with  moles? 
The  answer  should  be,  Deal  with  them  summarily  or  leave  them 
absolutely  alone.  If  the  mole  is  so  situated  as  to  be  irritated  by 
clothing  or  otherwise,  its  removal  is  positively  demanded;  the  only 
advice  given  by  the  physician  should  be  hi  any  case  to  remove 
them  all.  If  they  are  numerous  they  may  be  removed  at  several 
sittings.  Partial  removal  only  adds  to  their  danger.  Ligation  of 
the  pedicle,  with  a  view  to  strangulation,  should  never  be  prac- 
tised; it  leaves  the  base  of  the  tumor,  which  may  become  malig- 
nant. Excision  of  the  tumor  by  elliptic  incision  or,  in  the  smaller 
ones,  destruction  with  the  galvanic  needle  or  Paquelin  cautery 
are  the  most  approved  plans. 

Molluscum  Fibrosum  and  Neurofibromatosis. — Molluscum 
fibrosum  (fibroma  molluscum  or  molle)  is  a  condition  characterized 
by  the  development  of  soft  fibroids  in  the  skin  or  subcutaneous 
tissue.  They  are  multiple,  of  various  size,  and  wide  distribution. 
They  may  be  confined  to  a  single  region  or  be  indiscriminately 
distributed  over  the  body.  Molluscum  fibrosum  is  thought  to  be 
closely  allied  to,  or  even  a  manifestation  of,  one  form  of  multiple 
neurofibromatosis,  or  von  Recklinghausen's  disease.  The  periph- 
eral nerves  of  the  cerebrospinal  system  are  usually  affected,  but 
the  condition  has  been  seen  in  the  abdominal  sympathetic.  The 
nodules  may  be  confined  to  one  nerve,  on  which  a  single  node  or 
numerous  nodes  appear,  or  be  general  and  vary  in  number  from  a 
a  few  scattered  tumors  to  enormous  numbers, '  giving  the  nerves 
a  beaded  or  moniliform  appearance.  In  other  cases  the  nerve  and 
its  branches  are  involved  for  several  inches,  producing  a  peculiar 
network  of  fibrous  tissue  (plexiform  neuroma).  This  form  is 
either  congenital  or  appears  soon  after  birth.  Again,  when  the 
local  enlargement  is  extensive,  the  tumor  masses  may  grow  in 
such  form  and  position  as  to  cause  the  skin,  often  pigmented  and 
hairy,  to  sag  down  in  folds.  They,  too,  are  congenital  or  ac- 
quired in  the  early  years  of  life.  They  are  found  usually  on  the 
head  and  neck,  and  are  often  mixed  with  angiomatous  or  lymph- 
angiomatous  tissue.  Owing  to  their  similarity  to  localized  ele- 
phantiasis they  are  called  elephantiasis  nervorum.  According  to 
von  Brans  one-twelfth  of  all  cases  of  neurofibromatosis  succumb  to 
sarcomatous  changes.  Painful  subcutaneous  tubercle  is  a  small, 
painful,  sensitive  neurofibroma  occurring  on  a  peripheral  nerve 


FIBROMATA    (FIBROIDS) 


473 


[•ranch,  usually  in  the  lower  extremity,  but  occasionally  in  any 
part  of  the  body.  It  is  movable,  hard,  and  usually  about  the 
size  of  a  pea. 

Treatment. — The  treatment  of  these  conditions  is  removal  of 
the  tumor  masses.  There  are  two  centra-indications:  first,  the 
tumors  may  be  too  numerous,  when  nothing  can  be  done;  or  they 
may  involve  nerves  whose  importance  is  so  great  that  one  would 
not  risk  the  sacrifice  of  their  function,  even  when  grafting  or 


Fin.  101). — Neiirolibrniiuitosis.     The  mother,  sister,  and  daughter  of  this 
patient  all  had  the  same  disease. 

nerve  .-uture  might  give  good  chance  of  restoration  of  function. 
It  i<  iiM'loss  to  attempt  «li>section  of  the  tumor  from  the  nerve- 
lil>ers.  The  loeali/ed  tumors  in  fil>roiua  molluscum  and  in  ele- 
phantia-i-  nervorum  may  he  diss»rtr<l  out. 

Keloid  (Cheloid). — As  stated  previously,  this  growth  is  in  many 
re-.pt  >ets  unlike  a  tumor.  It  is  a  filmms  tis>ue  growth  originating 
in  scar-ti-sue.  The  division  of  keloids  into  spontaneous  and 
traumatic  is  probal>ly  incorrect,  all  of  them  lieing,  according  to 


474  PRINCIPLES    OF   SURGERY 

accumulating  evidence,  due  to  traumatism.  The  extent  of  the 
injury  and  the  size  of  the  resultant  scar  seem  to  have  no  influence 
upon  their  production;  they  occur  just  as  readily  after  small 
wounds  as  after  larger  ones.  They  unquestionably  are  influenced 
by  predisposition,  which  is  likely  congenital,  and  may,  as  in  the 
case  of  negroes,  who  have  a  marked  predisposition,  be  racial. 
They  occur  more  readily  in  infected  or  suppurating  wounds  than 
in  aseptic  wounds,  but  this  is  not  a  sine  qua  non.  When  an  indi- 
vidual once  develops  a  keloid,  it  is  highly  probable  that  under 
similar  circumstances  others  will  develop  in  the  same  or  hi  other 
parts  of  the  body. 

A  keloid  may  originate  in  a  scar  and  confine  itself  to  the  original 
site  of  that  scar,  giving  it  the  appearance  simply  of  an  overgrown, 


Fig.  110.— Keloid  of  chest. 

elevated,  hard  cicatrix.  The  needle  punctures  on  either  side  may 
each  show  a  small  keloid;  on  the  other  hand,  the  most  insignificant 
lesion,  which  did  not  even  break  the  upper  layers  of  the  skin,  or 
which  was  of  no  greater  consequence  than  a  bee-sting,  the  prick 
of  a  needle,  or  puncturing  the  lobules  of  the  ear  for  ear-rings,  may 
result  in  widely  spreading  growths  which  attain  sometimes  the 
area  of  several  square  inches.  They  seem  to  be  especially  prone  to 
follow  the  excision  of  sebaceous  cysts.  They  are  made  up  of  fully 
developed  tissue,  some  of  whose  strands  usually  are  of  a  hyaline 
character  (collagen)  with  fibroblasts  lying  between  them.  The 
appearance  of  keloids  is  characteristic.  They  are  smooth  and 
glistening;  are  devoid  of  hairs,  cutaneous  glands,  and  papilla? 


FIBROMATA    (FIBROIDS)  475 

mrr  their  surface;  are  hard  and  are  movable  over  the  underlying 
structures.  They  often  assume  bizarre  shapes.  Keloids  are  never 
ODcapeuIated,  but  at  their  borders  shade  gradually  away  into 
normal  connective  tissue.  The  surface  of  keloids  in  the  white 
man  is  red  and  remains  so,  not  blanching  with  age,  as  in  the  case 
of  cicatrices.  Occasionally  a  keloid  forms  in  a  part  of  a  scar,  as  I 
recently  saw  in  an  abdominal  incision  which  healed  per  primam. 
The  upper  two-thirds  of  the  scar  was  undergoing  normal  changes 
at  the  end  of  six  months,  while  the  lower  third  had  assumed 
a  distinct  keloid  appearance.  This  is  to  be  distinguished  from 
hypertrophied  scars,  for  in  the  latter,  due  to  infection,  the  usual 
changes  are  observed  to  follow,  while  in  the  keloid  continued 
growth,  both  in  width  and  thickness,  occurs.  Usually  keloids 
are  painless,  but  they  may  cause  moderate  discomfort  from  pain 
and  itching.  Occasionally,  unlike  any  other  mesoblastic  tumor, 
they  disappear  spontaneously.  This  is  a  rare  occurrence,  and 
probably  has  been  emphasized  by  confusion  of  keloids  with  ex- 
cessive scar  formation.  Again,  unlike  benign  tumors,  they  tend 
to  recur  in  situ  on  removal,  even  when  there  is  no  doubt  that  the 
whole  new  formation  has  been  excised.  Infection  unquestionably 
renders  such  recurrence  more  certain. 

Keloids  may  occur  on  any  surface  of  the  body.  They  are  most 
frequently  seen  on  the  face,  neck,  upper  arm  (following  vaccina- 
tion), shoulder,  anterior  surface  of  the  chest,  and  the  dorsum  of 
the  hand.  They  are  rarely  observed  on  the  palms  and  soles. 

Treatment. — The  treatment  of  keloids  is  very  unsatisfactory 
from  an  operative  standpoint.  They  may  be  safely  removed,  but 
promise  cannot  be  made  that  they  will  not  return.  For  several 
years  in  succession  we  used  the  same  woman  in  the  clinic  of  the 
Medical  Department  of  Vanderbilt  University,  removing  keloids 
from  the  ear-ring  punctures,  a  tumor  from  each  end  of  both 
punctures.  x-Rays  give  probably  the  best  results  so  far.  Thio- 
sinamiu  injected  directly  into  the  tumor  substance,  10  to  15  min- 
ims of  a  15  per  cent,  alcoholic  solution  being  injected  at  each  sitting, 
causes  reduction  in  size,  but  cannot  be  said  to  cure. 

Epulis. — This  is  a  tumor  originating  from  the  periosteum  cover- 
ing the  alveoli  of  the  jaws.  It  is  made  up  of  fibrous  tissue  which 
often  contains  giant-cell-  i  hence  its  frequent  classification  with 
sarcomata).  The  tumor  may  contain  bits  of  new-formed  bone. 
It  develops  in  Koth  the  upper  and  the  lower  jaw,  much  more  fre- 
quently the  latter,  is  much  more  common  in  females,  and  usually 
in  the  anterior  portion  of  the  jaws  (not  further  back  than  the  first 
molar).  They  originate  in  the  periostoum  at  the  neck  of  a  tooth, 
between  two  teeth,  or  from  a  tooth  socket.  They  are  pedunculated 
— ile,  rarely  attain  great  >i/e.  heing  no  larger  than  a  pigeon's 


476 


PRINCIPLES    OF   SURGERY 


egg.    If  the  tumor  originates  between  two  teeth  it  will  often  be 
found  protruding  both  from  the  lingual  and  the  buccal  side. 


Fig.  111. — Epulis  in  a  girl  aged  seventeen  years. 


Fig.  112. — Epulis.     Giant-cells  at  x  showing  throughout.     (Microphotograph; 

X  about  100.) 

They  may  be  soft  or  hard  and  are  covered  with  mucous  membrane, 
and  are  smooth  or  slightly  nodulated  or  berry-like,  unless  they 
are  ulcerated.  They  are  benign  in  their  behavior  in  most  in- 


FIBROMATA    (FIBROIDS)  477 

stances,  although  the  giant-celled  type  seems  to  be  justly  given 
as  a  subdivision  of  sarcoma.  They  cause  separation  or  deviation 
of  the  teeth,  interfere  sometimes  with  mastication,  and  are  un- 
sightly if  in  the  incisor  region. 

They  recur  when  removed  by  application  of  cauterizing  agents, 
active  or  potential,  and  can  be  relieved  only  by  excision  of  the 
periosteum  from  which  the  tumor  arises.  This  frequently  neces- 
sitates, unfortunately,  the  extraction  of  the  teeth  between  which 
the  tumor  grows.  It  is  seldom  necessary  to  remove  a  portion  of 
the  alveolus,  as  the  tumor  is  usually  of  periosteal  origin,  but  if  it 
is  bony  it  becomes  necessary  to  remove  a  portion  of  the  alveolus. 


CHAPTER    XXXVIII 
LIPOMA 


Definition.  —  A  lipoma  is  a  tumor  whose  essential  structure  is 
fatty  tissue. 

Classification.  —  Lipomata  are  usually  of  the  simple  encapsu- 
lated variety.  However,  the  capsule  may  be  incomplete,  allowing 
finger-like  processes  to  project  from  the  body  of  the  tumor  into  the 
joints,  and  called  lipoma  arborescens;  they  arise  from  synovial 


v 

• 

'**..- 


-r-'-. 


•••••'    S. 


,  •  -  .  "*  -.p^s  i 

:'l'  ; 

&    ' 

^   '       v 


.    "•*         f »        >>*•  - 

i- 

K,  x  ^t*y 

^ 

> — i .  .j.- 1         /  • . ' 


Fig.  113. — Lipoma. 


jphotograph;  X  40-) 


villi  and  external  to  the  pleura  and  peritoneum.  A  third  variety 
appears  as  a  large  fatty  mass  accumulated  in  the  subcutaneous 
connective  tissue,  and  spoken  of  as  a  diffuse  lipoma;  it  has  no 
semblance  of  a  capsule.  The  latter  probably  do  not  deserve  to 
be  classed  as  true  lipomata;  they  are  rather  subcutaneous  accu- 
mulations of  fat,  and  are  seen  usually  beneath  the  chin,  in  the 
axilla,  and  over  the  lower  abdomen. 

Xanthoma  or  xanthelasma  deserves  to  be  mentioned  here,  not 

478 


LI  POM  A 


479 


as  a  subdivision  of  lipomata,  but  because  it  is  a  small  tumor-like 
mass  whose  nature  and  etiology  are  not  understood;  it  is  some- 
times seen  in  diabetics. 

Etiology. — How  important  a  part  trauma  plays  in  the  causa- 
tion of  lipomata  is  uncertain.  Undoubtedly  they  do  sometimes 
follow  prolonged  irritation  of  the  subcutaneous  fat  by  pressure,  as 
is  seen  in  those  who  carry  heavy  loads;  this  is  probably  only  inci- 
dental, and  the  majority  come  independently  of  outside  influences. 
They  are  occasionally  symmetric,  which  would  suggest  tropho- 
neurotic  influence.  The  so-called  arborescent  lipomata  of  the 
large  articulations  frequently  are  associated  with  tuberculosis  of 
the  joint  or  with  arthritis  deformans. 


I 


Fin.  H4. — Lipoma  of  child's  neck. 


Fig.  115. — Ulcerative  lipoma  in  a 
child .   Weight  of  t  umor,  8  pounds. 


Structure. — The  fat  of  lipomata  cannot  be  easily  distinguished 
from  normal  fat.  It  is  paler,  and  the  cells  are  larger  than  in  normal 
fat  (Adami).  The  tumors  are  usually  encapsulated  with  a  thin 
but  definite  capsule.  The  fat  is  supported,  and  the  lobes  and 
lobules  are  separated,  by  a  connective-tissue  framework  just  as 
in  normal  fat,  and  the  blood-vessels  are  conducted  along  these 

septa. 

Sites  of  Formation. — The  vast  majority  of  lipomata  arise  in  the 
subcutaneous  fat,  the  neck,  shoulders,  back,  and  hips  being  the 
most  frequent  sites.  They  may  occur  in  any  region  of  the  body, 
even  appearing  rarely  in  the  palms  (beneath  the  palmar  fascia) 


480 


PRINCIPLES   OF   SURGERY 


and  the  soles.  They  are  rare  in  the  subcutaneous  fat  of  the  scalp. 
In  the  deeper  regions  of  the  body  (subaponeurotic)  lipomata 
develop  much  less  frequently.  They  are  sometimes  seen  arising 
beneath  the  occipitofrontalis  muscle  and  aponeurosis.  In  the 


Fig.  116. — Lipoma  of  forearm,  lying  beneath  vessels,  nerves,  and  tendons. 

abdominal  wall,  the  pectoral  region  of  the  chest,  the  neck,  and  the 
thigh  are  found  the  majority  of  intermuscular  (subfascial)  lipo- 
mata. Occasionally  they  develop  in  the  cheek  from  the  sucking 
cushion.  In  the  extraperitoneal  fat  and  in  the  perinephric  fatty 


Fig.  117. — Lipoma  of  mesentery.     Note  the  opened  intestine  at  top. 

capsule  fatty  tumors  may  arise  which  often  attain  enormous 
proportions.  The  same  may  be  said  of  the  mesenteric  fat.  The 
lipomata  found  surrounding  the  sac  of  inguinal  and  femoral 
herniae  belong  to  the  extraperitoneal  group.  Often  there  is,  in  cases 


LI  POM  A  481 

of  hernia,  an  excessive  quantity  of  fat  covering  the  sac,  and  in  a 
few  cases  it  makes  a  rather  large  tumor.  The  fatty  tumors  found 
in  the  kidney,  brain,  and  meninges  are  usually  small,  but  in  the 
kidneys  they  may  rarely  attain  great  size. 

Diagnosis. — Lipomata  are  usually  easily  recognized  if  they 
an  -ubcutaneous  tumors,  and  will  not  often  be  confused  with 
other  enlargements  in  the  subfascial  and  extraperitoneal  sites  if 
tin-  usual  points  of  development  be  remembered.  They  appear  as 
single  or  multiple,  occasionally  numerous,  tumors,  sometimes 
symmetric.  They  vary  in  size  from  insignificant  lumps  the  size 
of  a  l>ean  to  a  mass  of  50  or  60  pounds,  although  at  the  present 
day  individuals  usually  have  them  removed  before  they  reach 
<;it  at  si/.e.  They  usually  appear  at  some  time  between  the  twen- 
tieth and  fiftieth  year  of  life  and  grow  slowly  and  steadily;  occa- 
sionally one  stops  its  growth  for  a  time  without  known  cause, 
later  continuing  again.  They  are  flattened  or  roundish  tumors, 
re-i-mbling  usually  an  inverted  saucer  beneath  the  skin.  They  are 
thoroughly  movable,  both  in  relation  to  the  skin  and  to  the  under- 
lying structures.  The  skin  over  the  surface  is  smooth  and  normal 
hi  appearance,  except  for  the  unevenness  produced  by  lobulation, 
which  may  be  very  distinct.  An  attempt  to  lift  the  skin  away  from 
the  tumor  usually  results  in  the  so-called  dimpling,  or  retraction, 
of  the  skin  at  points  where  the  capsule  is  attached  to  the  skin  by 
connective-tissue  bands.  The  consistency  of  fatty  tumors  is 
described  as  being  doughy  or  that  of  wool  packed  into  a  sac. 
In  the  larger  tumors  fluctuation  may  be  so  apparent  as  to  lead 
one  to  the  diagnosis  of  a  cyst,  especially  if  the  tumor  is  deeply 
seated.  Pseudofluctuation  is  present  even  in  moderately  small 
tumors.  By  pressure  on  the  surface  of  the  tumor  its  soft  lobules 
can  usually  be  felt.  Pressure  on  the  edge  of  the  tumor  (the  flat- 
tened form)  causes  the  tumor  tissue  to  escape  suddenly  from  the 
grasp,  much  as  moist  orange  pits  are  thrown  by  compression  be- 
tween the  thumb  and  forefinger.  Lipomata  are  usually  sessile, 
but  may,  as  they  grow,  gradually  become  pedunculated.  When 
situated  under  a  vertical  surface,  especially  on  the  back,  they  may 
gradually  gravitate  to  a  lower  level,  so  that  after  a  time  they 
a>.-ume  an  entirely  new  position.  Application  of  ice  to  their  sur- 
face cau.-e>  hardening  of  the  ma>s.  Kinaciation  of  the  individual 
doe>  not  alter  the  course  of  lipoina  to  the  same  degree  as  normal 
fat.  The  nature  of  extraperitoneal  lipomata  and  those  occurring 
in  the  perinephric  fat  is  rarely  recognized  until  they  are  cut  down 
upon. 

Variations.  Lipomata  may  contain  a  large  proportion  of 
fibrous  ti.-sue.  showing  only  small  hits  of  fat  -cattered  throughout 
(fibrolipomata).  These,  of  course,  show  le.--  the  characteristics  of 
31 


482  PRINCIPLES   OF   SURGERY 

fatty  tumors.  They  are  harder  than  the  ordinary  lipoma.  Rarely 
bits  of  cartilage  or  bone  are  found  in  these  tumors.  It  is  question- 
able whether  these  masses  represent  a  mixture  of  types  or  meta- 
plasia. Exceptionally  a  lipoma  contains  a  large  supply  of  blood- 
vessels (lipoma  telangiectaticum) .  Myxomatous  lipoma,  or 
myxolipoma,  is  also  rarely  seen;  it  is  characterized  by  the  presence 
of  myxomatous  tissue  in  the  stroma  of  the  tumor. 

Pathologic  Changes. — Lipomata  are  not  frequently  altered  by 
accident  or  disease.  They  are  the  least  harmful  probably  of  the 
tumor  group.  The  fatty  tissue  may  become  edematous  and  de- 
generate, leaving  an  accumulation  of  oil  in  pockets  throughout  the 
tumor,  known  as  oil  cysts.  Mention  has  already  been  made  of  the 
occasional  appearance  of  bone  or  cartilage.  Calcification  of  the 
tumor  may  occur,  due  to  the  deposit  of  lime  salts  in  the  connective 
tissue.  Necrosis  and  ulceration  are  sometimes  observed  in  a  por- 
tion of  the  tumor.  Inflammation  may  develop  and  cause  the  gen- 
eral appearance  to  become  very  like  sarcoma.  The  history  of  an 
old  tumor,  and  of  recent  infection  or  traumatism,  and  the  ensuing 
signs  of  inflammation,  are  the  important  features  in  differentiation. 
Lipomata  are  the  most  benign  of  tumors,  yet  rarely  sarcomatous 
changes  occur,  with  the  usual  evidences  of  sarcoma. 

Prognosis. — The  outlook  for  an  individual  who  has  a  lipoma 
is  good.  The  tumors  can  be  safely  removed  and  do  not  return. 
If  incomplete  removal  is  done  in  diffuse  lipomata  the  portion  left 
in  the  tissues  will  probably  continue  to  grow. 

Treatment. — Lipomata  should  be  removed  when  recognized. 
They  will  usually  continue  to  grow  and,  especially  if  large,  become 
complicated  and  possibly  malignant.  Owing  to  their  subcutaneous 
position  and  the  size  they  may  attain,  it  is  often  better  to  excise 
an  elliptic  piece  of  skin  with  the  tumor  to  insure  better  closure 
of  the  wound. 


CHAPTER    XXXIX 


ANGIOMA    (HEMANGIOMA) 

Definition. — An  angioma  is  a  tumor  made  up  of  new-formed 
blood-vessels. 

Classification. — Three  types  of  angiomata  are  given,  namely, 
a i pillory  angioma  (nevus,  port-wine  stain,  birth-mark),  cavernous 
angioma,  and  plexiform  angioma  (cirsoid  aneurysm).  The  latter 
probably  does  not  belong  in  the  group  of  angiomata,  as  Adami  was 
unable,  hi  a  thorough  study,  to  find  evidence  of  new-tissue  forma- 


Fig.  118. — Capillary  angioma.     (Microphotograph;  X  about  100.) 

tion,  and  he  thinks  the  condition  is  due  to  a  congenital  weakness  of 
the  vessels  rather  than  to  tumor  formation,  as,  indeed,  he  con- 
siders most  of  the  so-railed  angiomata  to  be  telangiectaMi. 

Etiology. — The  majority  of  angiomata  are  congenital,  although 
they  may  at  the  time  be  almost  or  altogether  invisible.  Others 
:m-r  in  infants  during  the  first  or  second  year  of  life.  It  should 
be  remarked  here  that  many  children  show  red  splotches,  espe- 

483 


PRINCIPLES   OF   SURGERY 

cially  at  the  glabella  and  the  nape  of  the  neck,  which  disappear 
permanently  during  the  first  or  second  year.  Plexiform  angiomata 
develop  independently  of  any  known  cause  as  a  consequence  of 
irritation  or  trauma,  but  usually  from  a  pre-existing  angioma. 
Arborescent  varicosities  are  the  result  of  obstruction  or  senile 
changes,  and  sustain  no  relation  to  tumors.  Certain  angiomata 
seem  to  be  produced,  or  influenced  at  least,  by  disturbances  of  the 
nerve-centers. 

Structure. — Angiomata  represent  an  excessive  production  of 
permanent  vascular  tissue :  in  the  capillary  type  enlargement  and 
multiplication  of  capillaries,  in  the  cavernous  type  large  vascular 


Fig.  119. — Cavernous  angioma.     (Microphotograph;  X  about  100.) 

spaces  or  caverns.  The  types  are  often  mixed.  The  capillaries 
of  the  first  type  are  dilated  and  extremely  numerous.  They 
run  from  arterioles  to  veins,  and  are  unevenly  distributed  and 
separated  by  connective  tissue.  The  endothelial  lining  is  fre- 
quently several  layers  thick,  and  the  structure  of  their  walls 
resembles  that  of  the  arterioles.  The  cavernous  type  is  made  up 
of  caverns  which  are  filled  with  blood  and  communicate  with  the 
general  circulation .  The  septa  forming  the  partitions  may  contain 
blood-vessels  which  appear  normal.  The  structure  of  plexiform 
angioma  is  simply  an  increase  in  the  length,  diameter,  and  tortu- 
osity of  the  vessels,  with  thickening  of  the  vessel  walls. 


ANGIOMA  (HEMANGIOMA) 


4S5 


Sites  of  Formation. — Capillary  and  cavernous  angiomata  are 
found  especially  on  the  face,  head,  neck,  and  hands,  occasionally 
on  the  trunk  and  the  extremities.  Much  more  rarely  the  mucous 
membrane  of  the  mouth  and  tongue,  the  larynx,  the  bladder,  or 
the  uterus  show  them.  The  deeper  structures  are  sometimes 
affected,  as  the  salivary  glands,  the  breasts,  the  muscles,  especi- 
ally the  large  muscles  attaching  the  humerus  to  the  scapula; 
and,  finally,  the  viscera  are  very  infrequently  affected,  as  the 
liver,  kidneys,  spleen,  and  intestines.  The  confinement  of  angio- 
mata to  the  distribution  of  a  certain  nerve  or  group  of  nerves  is 
very  interesting.  The  distribution  of  the  fifth  nerve,  especially 


Fig.  120. — Cavernous  angioma.    The  blood  has  been  largely  washed  out  in  the 
process  of  staining;  a  few  cells,  however,  are  seen  at  x.     (X  about  100.) 

the  first  and  second  divisions,  is  especially  affected.  In  some  of  the 
nevi  in  the  distribution  of  the  fifth  nerve  it  is  known  that  a  cor- 
n -ponding  vascular  condition  affects  the  dura;  to  what  extent  this 
Matement  holds  true  is  not  yet  known.  Plexiform  angiomata  are 
usually  found  in  the  branches  of  the  anterior  division  of  the  super- 
ficial temporal  artery,  and  often  affect  anastomosing  branches  from 
collateral  vends,  Other  arteries  of  the  scalp  are  sometime- 
affected.  The  site  next  in  frequency  is  the  upper  extremity  below 
the  elbow. 

Diagnosis. — As  stated  already,  angiomata  are  usually  con- 
genital; this  is  by  no  means  an  absolute  rule.    If  not  congenital, 


486  PRINCIPLES   OF   SURGERY 

they  usually  appear  in  early  life.  The  "port-wine  stain,"  when 
purely  capillary,  is  recognizable  only  by  the  discoloration.  Its 
surface  may  be  on  a  level  with  the  surrounding  skin  or  slightly  but 
perceptibly  elevated.  It  may  vary  hi  size  from  a  pin's  head  to 
enormous  dimensions,  covering  an  area  of  half  the  face,  scalp, 
and  neck,  a  whole  extremity,  or  nearly  one-fourth  of  the  body 
surface.  The  color  of  a  birth-mark  varies  with  the  rate  of  replen- 
ishment of  its  blood;  hence,  it  may  be  a  bright  red,  bluish,  purplish 
or  a  dark  blue,  almost  black.  They  are  symptomless.  The  size 
at  birth  may  slowly  increase,  pan  passu  with  the  normal  develop- 
ment of  the  child,  or  the  growth  may  be  rapid,  so  that  a  previously 
insignificant  mark  may  hi  a  few  months  become  extensive.  The 
growing  capillary  nevi  often  assume  the  mixed  type,  and  the  tumor 
becomes  nodular  hi  appearance  and  produces  the  grossest  disfigure- 


Fig.  121. — Cavernous  angioma  of  prepuce. 

ment  by  thickening  the  lips,  the  cheek,  or  the  eyelids,  even  to 
complete  closure.  Pressure  on  a  capillary  angioma  forces  the 
blood  away  and  shows  a  normal  flesh  color,  but  instantly  the 
pressure  is  released  the  blood  rushes  again  into  the  vessels.  They 
are  occasionally  associated  with  an  excessive  growth  of  hair. 

Cavernous  angiomata  are  soft,  non-pulsating  tumors,  visible 
and  palpable,  fluctuant  and  collapsible  by  uniform  pressure.  They 
may  be  no  larger  than  a  pea  or  as  large  as  a  cocoanut,  and  mixed 
with  capillary  angiomata  or  altogether  independent  of  involvement 
of  the  tegumentary  capillaries.  If  there  is  no  associated  nevus 
the  tegument  covering  the  tumor  may  appear  of  normal  color; 
however,  if  the  blood  caverns  lie  close  to  the  skin  the  bluish 
color  of  the  underlying  blood  may  be  seen.  Crying,  straining,  or 
holding  a  deep  inspiration  increases  the  size  of  the  tumor.  In 


ANGIOMA  (HEMANGIOMA) 


487 


uncertain  cases  aspiration  with  a  fine  needle  brings  forth  pure 
blood.  Aspiration  in  suspicious  cases  should  always  be  done  with 
the  smallest  needle,  inserted  obliquely.  They  often  grow  with 
ext  reme  rapidity,  adding  new  caverns  or  enlarging  the  ones  already 
present.  Cavernous  angiomata  cause  absorption  of  the  tissues  in 
relation  with  them,  even  the  foramina  of  the  emissary  veins  which 
communicate  with  such  tumors  may  be  many  times  the  normal 
size.  Both  capillary  and  cavernous  angiomata  are  benign,  and  the 
true  telangiectases,  which  many  of  the  tumors  doubtless  are,  have 
no  new  tissue  elements  in  their  make-up.  Capillary  angiomata 
admit  moving  of  the  skin  normally  over  the  underlying  structures, 


I  it:   122. — Cavernous  angioma  of  the  tongue  in  a  man  seventy  years  old.     The 
growth  is  congenital. 

and  the  cavernous  type  may  be  surrounded  by  a  fairly  distinct 
cap-ule.  although  the  majority  of  them  doubtless  want  it. 

Angiomata  in  the  skin  supplied  by  the  fifth  nerve  may  have  an 
associated  angioma  of  the  dura,  which  occasionally  produces  for- 
midable complications,  as  epilepsy,  or  even  sudden  paralysis  or 
death  from  acute  hemorrhage  within  the  cranium. 

Plexiform  angiomata  cannot  be  well  confused  with  another 
cunilition.  The  presence  of  numerous  dilated,  tortuous,  pulsating 
arteries  associated  with  or  independent  of  previous  capillary 
angioma,  especially  the  red  ones  whose  circulation  is  rapid,  leaves 
no  chance  for  error.  The  bones  which  lie  in  contact  with  such 
vessels  are  grooved  and  tunneled  by  the  constant  pre>>ure. 

Occasionally  an  angiomatous  part  is  extremely  hypertrophied 


488  PRINCIPLES   OF   SURGERY 

or  overgrown.  A  lower  extremity,  for  example,  affected  by  an 
extensive  capillary  angioma  shows  sometimes  considerably  larger 
than  its  fellow. 

Cavernous  angiomata  in  the  mouth  may  become  so  large  as  to 
render  eating  difficult  and  conversation  impossible. 

Variations. — Angioma  frequently  appears  in  mixed  tumors,  as 
angiofibroma,  angiolipoma,  angiosarcoma,  and  angiolymphangi- 
oma.  The  angiomatous  element  frequently  escapes  notice  until 
operation  is  begun.  The  appearance  of  the  various  types  of  an- 
gioma in  a  single  tumor  has  been  sufficiently  discussed. 

Pathologic  Changes. — The  disappearance  of  certain  capillary 
angiomata  has  been  mentioned  already.  It  is  due  to  the  pro- 
liferation of  fibrous  tissue  and  the  consequent  obliteration  of  the 
vessels.  Even  capillary  angiomata  of  considerable  size  may  be 
thus  destroyed  or  reduced  hi  extent.  Inflammation,  ulceration, 
and  hemorrhage  may  occur  more  readily,  it  will  be  understood, 
hi  those  whose  circulation  is  slow.  Injury  is  likely  to  cause  pro- 
fuse or  fatal  hemorrhage  unless  pressure  is  applied,  which  easily 
accomplishes  the  purpose,  except  in  the  plexiform  type.  Some- 
times wart-like  elevations  appear  over  the  surface  of  an  angioma, 
and  in  others  a  fibrous-tissue  hyperplasia  occurs  between  the 
blood-vessels,  giving  the  part  the  likeness  of  elephantiasis,  ele- 
phantiasis hcemangiomatosa  (Kauffmann).  Phleboliths  are  some- 
tunes  seen;  angiomata  rarely  if  ever  become  sarcomatous;  epi- 
thelioma  sometimes  arises  over  the  tumor  surface,  but  it  is  in  all 
probability  independent  of  the  angioma. 

Prognosis. — The  prognosis  of  angiomata  is  good  unless  they 
begin  to  bleed;  they  then  become  dangerous.  They  cause  dis- 
figurement, and  hi  the  mouth  or  about  the  eye  interfere  with 
function.  They  are  frequently  safer  left  alone  than  operated  on, 
owing  to  the  danger  from  hemorrhage.  Therefore,  rapid  growth 
hi  small  tumors  should  always  be  a  positive  indication  for  im- 
mediate treatment.  Those  affecting  the  dura  are  dangerous 
because  of  pressure  and  possible  hemorrhage.  Recurrence  is 
often  seen. 

Treatment. — The  treatment  of  angiomata  hi  general  may  be 
summed  up  in  the  statement  that  the  vessels  should  be  obliter- 
ated or  removed.  In  very  young  infants  who  have  slight  nevi  it 
is  best  to  observe  them  for  a  time,  as  many  will  disappear;  the 
diminution  in  size  or  color  is  encouragement  to  wait  still  further. 

When  it  is  possible,  owing  to  the  size,  situation,  and  type  of  the 
tumor,  excision  is  the  best  plan  of  treatment;  but,  unfortunately, 
many  of  the  most  disfiguring  tumors  are  not  amenable  to  this  plan 
if  they  are  large,  as  the  resultant  defect  would  be  worse  than  the 
original.  Small  tumors,  either  capillary  or  cavernous,  may  usually 


ANQIOMA  (HEMANGIOMA)  489 

be  excised.  Cavernous  angiomata  in  loose  connective  tissue  and 
in  the  fat  may  be  excised.  In  all  instances  where  an  attempt  at 
excision  is  to  be  undertaken,  the  utmost  care  should  be  exercised 
to  avoid  incising  or  tearing  into  the  tumor  tissue,  particularly  if 
cavernous,  as  alarming  or  fatal  hemorrhage  may  result.  The 
vessels  supplying  the  tumor  should  be  double  ligated  as  they  are 
approached,  and  it  must  be  understood  that  many  of  these  are 
dilated  far  in  excess  of  their  normal  size,  partaking  of  the  same 
changes  found  hi  the  tumor.  If  any  of  these  vessels  make  their 
exit  from  bone  and  immediately  enter  the  tumor,  which  occurs  in 
cavernous  angioma  of  the  scalp,  they  can  frequently  be  con- 
trolled only  by  use  of  the  actual  cautery.  If  it  is  necessary  to  re- 
move an  angioma  on  account  of  its  interference  with  function, 
and  if  removal  is  impossible  without  cutting  through  the  clump  of 
vessels  or  caverns,  the  first  step  of  the  operation  should  be  liga- 
ture of  all  important  arteries  and  veins  communicating  with  it. 

Superficial  capillary  angiomata  may  be  satisfactorily  dealt 
with  without  cutting.  The  more  the  cavernous  element  is  present, 
the  less  applicable  the  plan.  The  most  satisfactory  plan,  perhaps, 
is  to  freeze  the  surface  through  the  whole  thickness  of  the  tumor 
with  carbon-dioxid  snow.  The  depth  to  which  the  freezing  reaches 
is  determined  by  the  number  of  seconds  of  application  and  the 
firmness  of  pressure,  which  cuts  off  the  circulation  from  the  area 
under  treatment.  If  the  tumors  cover  a  large  surface,  several 
sittings  should  be  had.  The  use  of  the  galvanic  needle  in  angio- 
mata of  considerable  size  is  a  worthless  form  of  torture,  for  the 
patients  become  disgusted  and  leave  off  their  treatment  long  be- 
fore it  is  finished,  as  witness  the  large  number  of  old  angiomata 
dotted  with  little  islands  which  represent  the  sites  of  puncture. 

Cavernous  angiomata  that  cannot  be  removed  by  dissection 
may  be  cured  by  the  injection  of  boiling  water  directly  into  the 
tumor  mass.  An  ounce  is  a  sufficient  dose,  and  when  the  clot 
has  absorbed  the  injection  may  be  repeated  at  a  new  point.  Care 
must  be  taken  not  to  burn  the  skin,  as  sloughing  and  possible 
hemorrhage  will  result.  The  procedure  produces  little  or  no  pain 
unless  the  skin  is  burned.  The  dangers  of  this  method  theoretically 
are  embolism  and  infection,  although  I  know  of  no  instance  of 
either. 

Plexiform  angiomata  present  a  difficult  and  often  unsolvable 
problem.  They  may  l>e  treated  best  by  ligating  all  the  feeding 
arteries  and  removal  of  the  dilated  vessels.  If  this  cannot  be  done 
the  tumor  had  best  l>e  left  alone.  In  determining  whether  to  ex- 
ci>e  or  leave  plexiform  angiomata,  the  first  question  to  decide  is 
whether  the  vessels  can  lie  -pared  without  sacrifice  of  the  tissues 
they  supplv.  On  the  extremities  amputation  may  be  required. 


CHAPTER    XL 

LYMPHANGIOMA 

THIS  tumor  is  made  up  essentially  of  new-formed  lymph- 
spaces  and  channels.  It  sustains,  in  a  sense,  the  same  relation  to 
the  lymphatics  that  angioma  does  to  the  blood-vessels,  with  this 
important  exception,  namely,  that  the  new-formed  vessels  and 
spaces  in  lymphangiomata  do  not  communicate,  at  any  rate 
freely,  with  the  normal  lymphatics.  The  same  difficulty  is  en- 
countered here  as  in  angiomata,  on  account  of  the  presence  of 


i» •  »/..•**»••,...     f.'     1       »:.'.  fcA.i-        >»•<»  1  >— •      1 

Fig.  123. — Lymphangioma.     (Microphotograph ;  X  about  100.) 


lymphangiectases,  which  cannot  be  regarded  in  any  true  sense 
as  tumors. 

Classification. — There  are  three  distinct  types  of  lymph- 
angioma.  First,  simple  lymphangioma,  which  is  made  up  of  lymph- 
atic vessels,  large  and  small,  bound  together  into  a  bundle  or  mass. 
In  this  type  the  vessels  may  be  more  or  less  dilated,  but  not  to 
the  degree  found  in  the  second  class.  There  are  all  degrees  of 
gradation  between  the  first  and  second  types.  Second,  cavernous 
lymphangiomata,  which  are  spongy  masses  of  caverns  and  spaces 

490 


LYMPHANGIOMA 


491 


held  together  by  connective  tissue  and  muscle-fibers  (unstriped), 
and  separated  from  each  other  by  septa  which  constitute  their 
walls.  The  most  frequent  examples  of  the  cavernous  type  is  seen 
in  macrocheilia  and  macroglossia.  Third,  lymphangioma  cysticum 
or  cystic  hygroma  (hygroma  cysticum  colli  congenitum)  is  the  most 
interesting  type  in  many  respects.  It  is  made  up  of  a  large  number 
of  cysts  of  varying  sizes  and  independent  of,  or  communicating 
with,  each  other. 

Etiology. — The  vast  majority  of  lymphangiomata  are  of  con- 
genital origin,  like  angiomata,  a  fact  which  points  to  their  cause 
in  the  majority  of  cases  as  imperfect  or  misdirected  development, 
rather  than  to  an  origin  similar  to  that  of  other  tumors  and 


V\K.  124. — Cystic  hygroma  of  the  neck  in  a  child  two  months  of  age. 

equally  obscure.  Postnatal  lymphangiomata  do  arise  even  as  late 
a>  t  ho  menopause,  and  they  may  develop  subsequent  to,  and  at  the 
site  of,  a  recent  trauma,  if  not  as  its  direct  consequence.  Some 
lyinphangiomata  are  unquestionably  of  new  formation,  but  most 
of  them  are  due  to  obstruction  or  developmental  disturbances,  and 
appear  usually  at  sites  where  fetal  fissures  and  clefts  have  closed. 
Structure. — The  tumors  are  made  up  of  the  various  spaces 
<li  -cribed  alxrve,  lying  in  the  midst  of  a  connective-tissue  frame- 
work and  lined  with  endothelium.  They  contain  a  clear  fluid 
(lymph),  or  in  the  cystic  type  it  may  be  clear,  turbid  and  milk- 
like,  or  chocolate  brown,  and  show  the  presence  of  de'bris  and 
cholesterin.  The  dark  discoloration  is  due  to  the  escape  of  blood 
into  the  cysts. 


492 


PRINCIPLES   OF   SURGERY 


Sites  of  Formation. — Single  lymphangiomata  are  found  essen- 
tially in  the  skin  and  in  subcutaneous  tissues,  most  frequently 
in  the  face  and  neck.  Cavernous  lymphangiomata  are  usually 
seen  as  congenital  malformations  of  the  lips,  macrocheilia,  or 
of  the  tongue,  macroglossia,  in  which  organs  they  may  produce 
most  disfiguring  and  harmful  lesions.  Other  regions  may  be  af- 
fected by  this  type.  The  cystic  type  is  found  most  frequently  hi 
the  neck,  and  may  extend  as  low  as  the  clavicle  or  as  high  as  the 
ear  or  the  ramus  of  the  jaw.  They  sometimes  appear  also  in  the 
region  of  the  shoulder,  the  axilla,  the  abdomen,  the  sacrum,  and  the 
groin.  They  are  rarely  found  hi  the  mesentery,  and  hi  this  location 
they  contain  a  chyle-like  fluid. 


Fig.  125. — Sac  of  large  axillary  cyst.     Cystic  hygroma. 

Diagnosis. — The  majority  of  lymphangiomata  are  congenital, 
although,  as  already  stated,  some  may  arise  hi  advanced  life. 
The  simple  form  appears  usually  as  a  diffuse  tumor,  with  little  or 
no  evidence  of  encapsulation;  the  cavernous  type  also  is  diffuse. 
These  two,  therefore,  will  rarely  be  found  as  distinct  tumor 
masses  independent  of  the  tissues  of  the  region,  but  rather  as 
invading  the  structures,  producing  an  apparent  hypertrophy  of  the 
part.  The  cavernous  tumors  sometimes  form  a  distinct  mass,  which 
is  poorly  circumscribed.  They  constitute  soft,  flabby,  elastic 
tumors,  and  have  a  consistence  resembling  that  of  lipomata. 
Macrocheilia  and  macroglossia  may  be  of  such  dimensions  as  to 
produce  the  most  hideous  deformity,  the  tongue  being  so  greatly 


LYMPHANOIOMA  493 

enlarged  as  to  protrude  from  the  mouth  and  preclude  the  possi- 
bility of  speech  and  mastication  and  produce  marked  discomfort. 
The  cystic  variety  may  reach  an  enormous  size,  especially  when  it 
is  considered  that  they  are  found  in  infants,  in  whom  they  may 
frequently  attain  the  size  of  an  orange,  and  occasionally  become 
almost  as  large  as  a  child's  head.  Some  of  these  cystic  tumors  fail 
to  grow  for  a  long  period  of  time,  and  later,  even  in  adults,  may 
grow  rapidly  to  troublesome  dimensions.  They  may  be  fluctuant 
or  not,  dependent  upon  the  size  of  the  individual  cyst  cavities  and 
the  amount  of  connective  tissue  separating  them  and  their  dis- 
tribution among  the  normal  anatomic  structures.  The  cyst 
shown  in  Fig.  124  was  fluctuant,  but,  on  attempting  to  dissect  it 
away,  the  whole  side  of  the  neck  was  found  to  be  filled  with  smaller 
cyst:-  lying  around  the  great  vessels,  among  the  nerves  of  the 
cervical  and  brachial  plexuses,  and  in  the  intermuscular  spaces 
deeper  than  the  scaleni.  The  cystic  variety  is  distinctly  trans- 
lucent if  transillumination  can  be  done,  unless  the  fluid  happens 
to  be  opaque.  They  are  to  be  distinguished  from  cysts  occurring 
in  the  neck  in  vestiges  of  the  gill-slits.  The  latter  are  lined  with 
epithelium,  are  single,  simple  cysts,  and  do  not  invade  the  struc- 
tures surrounding  them. 

Variations. — There  is  frequently  present  in  other  benign  tumors 
an  excessive  quantity  of  lymphangiomatous  tissue,  and  it  may  be 
abundant  enough  at  times  to  justify  the  name  of  a  mixed  tumor. 
They  are  especially  liable  to  be  mixed  with  angioma. 

Pathologic  Changes. — Changes  are  not  frequent.  When  a 
simple  or  cavernous  lymphangioma  is  wounded  there  may  be  a 
copious  discharge  of  lymph  which  continues  for  an  indefinite  time. 

Prognosis.— -Of  themselves  they  cause  no  harm.  Situated  in 
the  neck  or  pharynx,  in  the  mesentery  or  the  pelvis,  they  may  be 
responsible  for  serious  interference  with  physiologic  processes,  and 
in  the  region  of  the  neck  and  pharynx  may  cause  sudden  death. 
The  cystic  hygromata  occasionally  disappear  spontaneously. 
They  do  not  become  malignant. 

Treatment. —The  ideal  treatment  of  lymphangiomata,  as  in 
other  benign  tumors,  would  be  excision.  Manifestly,  from  the  diffu- 
sion of  the  tumor  mass  such  treatment  is  often  impossible.  In  that 
ea-f.  contrary  to  the  general  rule  in  benign  tumors,  one  may  remove 
a-  much  of  the  tumor  as  po-^iblc,  with  no  fear  on  account  of  the 
portion  left;  or  in  tho-r  cases  like  maeroglossia  and  macroeheilia, 
where  an  anatomic  structure  must  be  reduced  in  size,  such  reduc- 
tion is  accomplished  by  excising  portions  of  the  tongue  or  lip, 
n-ganllr.—  of  the  amount  of  lymphatic  tissue  or  muscle  removed. 
If  the  growth  continue.-  the  treatment  must  be  repeated. 


CHAPTER    XLI 

MYOMATA 

Definition. — A  myoma  is  a  tumor  whose  essential  tissue  is 
muscle-fiber. 

Classification. — There  are  two  types  of  myoma — namely, 
leiomyoma,  which  is  made  up  of  unstriped  muscle  tissue,  and 
rhabdomyoma,  whose  muscle-fibers  belong  to  the  striped  or  volun- 
tary variety.  The  latter  is  a  very  rare  form,  so  rare,  indeed,  that 
certain  authors  have  disputed  its  existence,  while  the  former  is 


tVi&SGtvi  >.  •  \.-4>  *X  , 


Fig.  126. — Leiomyoma  of  uterus.  The  heavy  bundles  of  muscle-fibers 
are  seen  in  long  (z)  and  transverse  (o)  section  and  in  separate  nodules  («)  and 
connective  tissue  (c)  between.  (X  about  100.) 

very  common,  although  they  do  not  appear  without  the  admixture 
of  connective  tissue,  frequently  of  other  tissues.  This,  however,  is 
in  a  sense  true  of  practically  every  tumor,  benign  or  malignant. 

Etiology. — The  fact  that  the  appearance  of  myomata,  espe- 
cially in  the  uterus,  is  more  frequent  than  that  of  any  other  tumor 
has  added  nothing  definite  to  our  understanding  of  its  cause.  Cell- 

494 


MYOMATA  495 

rests  have  not  been  discovered.  It  has  been  supposed  to  occur  less 
frequently  in  women  who  have  borne  children;  the  converse  state- 
ment is  probably  nearer  the  truth — namely,  that  women  who  have 
uterine  tumors  do  not,  as  a  rule,  become  pregnant,  as  these  tumors 
are  one  of  the  common  causes  of  sterility.  They  occur  in  the 
uterus  after  puberty,  more  frequently  hi  certain  families,  and 
certainly  with  great  frequency  in  negroes.  The  presence  or  ab- 
sence of  infection  seems  to  have  no  influence,  although  some  have 
claimed  that  adenomyomata  may  be  due  to  this  cause.  Noth- 
ing is  known  of  the  cause  of  leiomyomata,  which  occur  outside 
the  uterus,  and  of  rhabdomyomata  further  than  what  has  been 
<dvrn  hi  the  discussion  of  the  origin  of  tumors  in  general. 

Structure. — Leiomyomata  are  very  similar  in  structure  to 
tiliromata  (mutatis  mutandis),  and  are  often  difficult  to  distinguish 
from  the  latter.  Indeed,  they  vary,  in  their  relative  quantity  of 
plain  muscle  and  fibrous  tissue,  from  the  "pure  leiomyoma" 
to  the  fibroid,  which  shows  no  muscle  tissue  at  all.  They  are 
clearly  delimited  from  the  surrounding  tissue  and  encapsulated, 
although  some  of  them  are  rather  firmly  attached  to  the  surround- 
ing tissue  by  the  formation  of  excessive  fibrous  tissue  around 
the  blood-vessels  which  enter  the  tumor.  The  softer  variety,  or 
purr  myoma,  is  cut  more  easily  than  the  more  fibrous  (fibroid 
tumors),  and  shows  a  reddish-gray  cut  surface,  while  the  more 
fil irons  type  conforms  to  the  appearance  of  fibromata  and  shows 
a  white  cut  surface,  and  produces  a  grating  sensation  on  being  cut. 
The  pure  myomata  are  firmer  than  normal  uterine  tissue  and  the 
fibroids  are  much  firmer  and  more  difficult  of  section.  Leiomyo- 
mata are  often  nodulated. 

Rhabdomyomata  show  the  presence  of  more  or  less  imper- 
fectly developed  striated  muscle-fibers,  which  are  found  lying 
among  round  or  spindle-shaped  cells.  These  tumors  are  some- 
tin  irs  sarcomatous. 

Sites  of  Formation. — Leiomyomata  develop  hi  connection 
with  those  structures  which  normally  contain  smooth  muscle- 
filtrrs;  they  are  found  with  greatest  frequency  in  the  uterus,  and 
commonly  pass  under  the  name  of  fibroid  tumors  of  the  uterus. 
They  are  found  in  the  walls  of  the  alimentary  tract,  from  esopha- 
,uus  to  the  large  intestine,  and  rarely  in  the  urinary  bladder.  The 
skin  may  serve  as  a  point  of  origin,  usually  giving  rise  to  very 
small  tumors.  Cases  have  been  reported  of  myomata  of  the 
scrotum  and  the  vulva.  Rarely  they  are  found  in  the  ovary. 

Khalxlomyomata,  unlike  other  brnijrn  tumors,  do  not  originate 
in  connection  with  voluntary  mu-i-le  tissue;  they  are  always 
heterotogOtUL  They  arc  extremely  rare;  found  most  frequently 
in  the  kidney,  they  may  al>o  ari-e  from  the  testicle  or  the  urinary 


496  PRINCIPLES   OF   SURGERY 

bladder:  striated  fibers  have  been  observed  in  tumors  of  the 
heart  in  syphilitic  infants,  bat  they  probably  do  not  belong  to  the 
tumor  group.  Orlandi  has  found  this  tumor  originating  in  con- 
nection with  nerve  tissue. 

Diagnosis. — The  presence  of  myomata  may  be  suspected 
chiefly  by  the  fact  that  a  slow-growing  movable  encapsulated 
tumor  is  found  in  connection  with  an  organ  well  supplied  with 
plain  muscle-fibers.  The  softer  tumors  are  more  myomatous, 
the  harder  ones  fibrous.  No  sharp  diagnostic  line  can  be  drawn 
between  the  two  hi  a  clinical  way,  and  none,  indeed,  is  necessary. 
They  vary  from  the  size  of  a  shot  to  that  of  a  man's  head  or, 
rarely,  even  larger.  They  may  be  smooth  and  round  when  of 
moderate  size,  but  as  they  grow  larger  they  become  nodulated, 
and  sometimes  present  a  tangled  mass  of  tumors,  some  of  which  are 
widely  attached  to  the  organ  from  which  they  arise,  or  attached  to 
it  and  to  one  another  by  such  small  pedicles  as  could  not  nourish 
them  except  for  adhesions  attaching  them  to  other  structures,  as 
the  omentum  in  myomata  of  the  uterus.  The  attachment  of  the 
omentum  often  bears  unmistakable  evidence  of  the  source  of  the 
chief  blood-supply  to  the  tumor  in  the  numerous  and  enormously 
enlarged  veins  and  arteries  connecting  the  two.  The  tumors  may 
be  single,  but  in  the  uterus  are  often  multiple  and-  sometimes 
numerous.  In  the  cases  of  multiple  myomata  they  are  seen  in  all 
stages  of  development,  a  very  young  one  lying  alongside,  but  inde- 
pendent of,  a  large  and  old  tumor.  In  the  uterus  they  appear  as 
submucous,  mural,  or  subserous  tumors.  The  mural  type  may  be 
a  diffuse  growth,  occupying  or  displacing  the  whole  body  of  the 
organ.  The  submucous  tumors  are  frequent  causes  of  abnormal 
uterine  hemorrhage,  of  dysmenorrhea,  sterility,  and  abortion, 
and  present  grave  complications  at  times  when  labor  occurs  at 
term. 

Edematous  cystic  myomata  and  those  softened  by  degenerative 
changes  cannot  be  distinguished  in  many  instances  from  intra- 
abdominal  cysts.  Myomata  may  grow  for  years,  attain  a  moderate 
size  not  uncomfortable  to  the  patient,  and  then  cease  to  grow 
further.  The  old  belief  that  they  disappear  at  the  menopause  is 
untrue  and  dangerous.  Rhabdomyomata  cannot  be  recognized 
clinically  as  such. 

Variations. — Fibromyoma  is  the  usual  form  of  myoma,  pure 
leiomyoma  being  rare;  the  fibrous  tissue  may  predominate,  or  the 
muscle  tissue,  producing  hard  or  soft  tumors  respectively.  Acleno- 
myomata  have  been  demonstrated  to  occur  with  considerable 
frequency,  and  are  due,  it  is  thought  (Cullen),  to  a  "flowing"  of 
the  epithelial  lining  of  the  uterus  into  its  musculature.  Myomata 
rarely  show  the  presence  of  lymphangiectases  or  telangiectases. 


MYOMATA  497 

Pathologic  Changes. — One  of  the  frequent  accidents  befalling 
myomata  in  their  most  frequent  site  is  inflammation  of  the  surface 
and  fixation  of  the  tumor  to  the  surrounding  intestines  by  adhe- 
sions, which  may  become  very  dense  and  vascular.  Furthermore, 
inflammation  may  cause  edema  of  the  tumor,  suppuration,  and 
thrombosis.  Pregnancy  and  labor  favor  these  conolitions. 

Fatty  degeneration,  associated  with  hyaline  degeneration  and 
necrosis  of  the' muscular  element,  is  very  frequently  seen,  and  these 
changes  may  result  in  a  reduction  of  the  size  of  the  tumor  with 
increased  hardness.  Calcification  occurs  usually  in  old  women, 
but  not  altogether,  and  may  be  found  only  in  isolated  spots  as  a 
shell  surrounding  the  tumor,  or  throughout.  Of  course,  calcifica- 
tion precludes  the  possibility  of  further  growth  in  the  parts  affected. 
Such  calcified  tumors  have  been  known  to  be  cast  off  through  the 
vagina  or  even  through  the  rectum  or  bladder  (uterine  stones). 

Cystic  changes  arise  from  several  causes — first,  as  a  result  of 
hemorrhage  into  the  tumor  substance;  second,  from  lymphangiec- 
tases;  third,  from  myxomatous  degeneration  of  the  connective 
tis>ue,  and,  fourth,  in  adenomyomata  from  the  action  of  the  epi- 
thelial cells  included  in  the  tumor  mass. 

Ulceration  of  submucous  tumors  and  consequent  hemorrhage 
is  not  an  unusual  occurrence. 

Pedunculated  tumors  may  become  edematous  and  increased 
in  si/r.  or  necrotic  by  torsion  of  the  pedicle. 

Myomata  do  not  frequently  become  sarcomatous,  but  do  so 
sufficiently  often  to  demand  a  close  supervision  over  them  when 
for  any  reason  removal  is  not  done.  The  increased  rate  of  growth 
or  the  renewed  growth  of  quiescent  myoma  should  be  accepted 
clinically  as  positive  evidence  of  malignancy. 

Prognosis. — Myomata,  by  virtue  of  their  frequent  origin  hi 
the  uterus  and  the  broad  ligaments,  offer  especial  dangers  to  the 
health  and  life  of  women  which  are  not  usual  with  benign  tumors. 
They  are  especially  liable  to  what  the  late  Dr.  Richard  Douglas 
•  ailed  malignancy  of  position.  They  are  often  carried  until  they 
reach  enormous  dimensions  without  harm,  and  are  finally  removed 
purely  because  of  their  disfigurement  or  burdensomeness.  On 
the  other  hand,  even  small  tumors  may  cause  most  ungrateful 
disturbance-  or  be  beset  by  dangerous  complications.  The 
danger  of  inalignaney,  though  small,  must  not  escape  us. 

Treatment. — The  general  rule  for  treatment  of  tumors  obtains 
here  as  elsewhere.  The  tumors  should,  when  it  is  possible,  be 
removed  and  the  organ  in  which  they  arise  left  in  position.  Hence, 
in  uterine  tumor-  myomectomy  should  always  be  given  preference 
(ccrtcris  paribux).  But  the  position  of  the  tumors,  their  number, 
their  size,  the  di-tortion  they  have  produced  in  the  body  jmd  the 


498  PRINCIPLES   OF   SURGERY 

canal  of  the  uterus,  the  complications  that  have  befallen  them,  and 
the  age  of  the  patient,  rendering  the  retention  of  the  uterus  im- 
perative or  superfluous,  are  the  factors  which  must  be  weighed 
by  the  surgeon  who  wishes  to  err  neither  on  the  side  of  wasteful 
conservatism  nor  on  that  of  unnecessary  sacrifice  of  possibly  useful 
organs. 

Rhabdomyomata  are  to  be  treated  as  any  other  benign  tumor, 
only  after  having  made  sure  by  microscopic  examination  that  they 
contain  no  sarcoma  cells. 


CHAPTER   XLII 
NEUROMA 

A  NEUROMA  is  a  tumor  which  essentially  contains  new-formed 
diluents  of  nerve  tissue. 

The  term  "neuroma"  has  been  used  heretofore  in  a  very  broad 
and.  as  recent  investigations  have  proved,  a  very  loose  sense. 
In  order  for  a  neuroma  to  be  true  to  the  significance  of  the  name 
it  must  contain  new-formed  nerve  elements;  the  simple  fact  that 
the  tumor  has  developed  in  connection  with  and  contains  nerve 
clcnicnt >  that  antedate  the  origin  of  the  tumor  no  longer  being 
accepted  as  a  justification  for  classifying  them  in  this  group. 
Thus,  many  tumors  have  been  removed  from  the  neuroma  group 
and  placed  hi  the  fibroma  group,  where  they  logically  belong; 
von  Reeklinghausen's  disease,  molluscum  fibrosum,  plexiform 
neuromata,  painful  subcutaneous  tubercle,  and  the  so-called 
amputation  neuromata,  while  they  all  doubtless  originate  hi  con- 
nection with  nervous  tissue,  are  eliminated  from  the  neuroma 
group;  "amputation  neuromata"  are  in  no  sense  justifiably  classed 
as  tumors,  since  they  are  made  up  of  scar-tissue  into  which  re- 
generating nerve-fibers  have  grown  hi  consequence  of  their  sever- 
ance. Since  all  the  pathologic  conditions  (false  neuromata)  have 
l>een  placed  where  they  belong,  the  term  neuroma  in  its  meaning 
en il  traces  an  exceedingly  small  number  of  tumors. 

Classification. — There  is  only  one  single  tumor  that  can,  with 
accuracy,  be  given  as  a  neuroma — namely,  the  ganglion-celled 
neuroma.  Another,  however,  is  of  such  close  relation,  by  virtue  of 
its  origin  from  specialized  cells  found  only  in  connection  with  the 
central  nervous  system,  that  it  will  be  discussed  here,  with  the 
admi» i«>n  that  it  has  long  been  considered  as  being  a  type  of 
sarcoma. 

Etiology. — Neuromata  are  thought  to  be  of  developmental 
origin,  as  the  majority  of  them  have  been  discovered  hi  very 
young  children. 

Structure. — Neuromata  are  made  up  of  ganglion  cells,  axones, 
and  dendrites  supported  by  neuroglia.  The  norve-fibers  found  in 
these  tumors  ;nv  largely  non-medullated;  a  few  are  medullated. 

Sites  of  Formation. — Neuromata  are  found  in  connection  with, 
or  in  the  region  of,  ganglia  and  in  the  skin  or  subcutaneous  tissue. 
They  may  develop  also  in  the  cerebral  ventricles  and  theependyma. 

m 


500  PRINCIPLES   OF   SURGERY 

Diagnosis. — Neuromata  are  seen  so  rarely  that  one  could 
scarcely  have  the  hardihood  to  risk  a  diagnosis.  They  are  slow- 
growing  tumors  and  cannot  be  distinguished  from  fibromata  of 
similar  consistence.  They  usually  appear  in  early  life  and  may  be 
congenital.  They  are  usually  of  moderate  size,  although  cases 
have  been  reported  as  large  as  a  child's  head.  The  cutaneous 
tumors  may  be  multiple  neuromata  and  behave  throughout,  so  far 
as  we  know,  as  benign  tumors,  but  should  be  excised  when  it  is 
possible  to  do  so. 

GLIOMA 

This  tumor  is  derived  from  the  neuroglia  of  the  central  nervous 
system.  The  relation  of  this  tumor  to  sarcoma  has  given  rise  to 
much  learned  discussion.  However,  the  origin  of  neuroglia  from 
the  epiblastic  layer,  and  the  general  behavior  of  the  tumor,  has 
led  to  the  conclusion  that  they  cannot  be  sarcomatous. 

Gliomata  are  classified  into  hard  glioma  (glioma  durum)  and 
soft.glioma  (glioma  molle).  Occasionally  the  gliomatous  substance 
is  associated  with  abundant  dilated  blood-vessels,  glioma  telan- 
giectaticum. 

Structure. — Gliomata  are  made  up  of  glia  cells,  their  processes 
and  the  fibrillar  network,  as  seen  in  the  normal  neurogliar  struc- 
ture. The  cells  are  oval  or  round  and  mononucleated.  The  greater 
the  cellular  content,  the  softer  the  tumor,  while  abundance  of 
fibrillar  elements  causes  the  tumors  to  be  hard.  In  retinal  gliomata 
the  fibrillse  are  almost  altogether  wanting,  although  the  cell 
processes  may  be  seen.  Retinal  gliomata  are  frequently  referred 
to  under  the  name  of  neuro-epitheliomata,  and  sometimes  as  glio- 
sarcomata.  The  arrangement  of  the  cells  surrounding  the  capil- 
laries is  radial;  there  appear  sometimes  also  resets  of  cells  due 
to  the  radial  disposition  of  cylindric  cells. 

Sites  of  Formation. — Gliomata  develop  only  in  connection 
with  the  central  nervous  system.  Adami  claims  that  they  occur 
only  in  the  brain,  in  the  retina,  and  rarely  in  connection  with 
cerebral  nerves,  and  that  the  excessive  glia  tissue  found  in  syringo- 
myelia  is  a  gliomatosis.  The  hard  variety  is  found  only  in  connec- 
tion with  the  ventricular  walls  and  projecting  into  the  ventricles. 

Diagnosis. — The  recognition  of  gliomata  of  brain  or  cord  can- 
not be  made  clinically.  They  produce  symptoms  of  pressure,  as 
do  other  tumors  similarly  situated.  The  hard  variety  are  well- 
defined  tumors  and  can  be  enucleated  satisfactorily,  but  the  soft 
gliomata  infiltrate  the  surrounding  brain  substance  in  such  a 
manner  as  to  render  it  impossible  to  recognize  where  tumor  tissue 
stops  and  brain  tissue  begins.  They  are  slow-growing  tumors. 
Hemorrhages  occur  frequently  in  the  soft  tumors,  attended  with 


NEUROMA  501 

evidence  of  sudden  increased  pressure  (apoplexy).  The  retinal 
form  of  glioma  occurs  in  the  young  or  may  be  congenital;  they  are 
often  bilateral;  often  one  eye  will  be  invaded  some  months  after 
the  other  has  been  enucleated.  Several  members  of  the  family  may 
be  affected,  or  they  may  apparently  be  transmitted  from  parent 
to  child.  Retinal  gliomata  may  grow  forward  and  cause  ulcera- 
tion  of  the  cornea  or  sclerotic  coat  and  protrude.  This  form  in- 
fi Unites  the  surrounding  tissues,  and,  unlike  the  central  form, 
produces  metastases  (retinal  gliosarcoma). 

Prognosis. — The  prognosis  of  gliomata  is  unfavorable;  the 
cerebral  type,  by  virtue  of  its  location  in  an  organ  where  localiza- 
tion and  treatment  are  alike  difficult,  and  where  the  tendency  to 
hemorrhage  may  at  any  moment  cause  sudden  death  or  permanent 
crippling;  the  retinal  type,  because  of  the  inherent  malignancy, 
with  consequent  infiltration  perhaps  along  the  optic  nerve  to  the 
cranial  cavity,  and  metastasis.  The  least  harm  it  can  do  is  to 
cause  the  loss  of  one  or  both  eyes. 

Treatment. — The  only  treatment  is  removal. 


CHAPTER   XLIII 

SARCOMA 

Definition. — Sarcoma  is  a  tumor  made  up  of  embryonic  meso- 
blastic  cells.  It  is  the  malignant  type  of  connective-tissue  tumor, 
exclusive  of  those  derived  from  endothelial  cells  (endotheliomata). 

Classification. — There  are  several  types  of  cells  found  in  sarco- 
mata, and  they  are  accordingly  classified  as  small  round-celled 
sarcoma,  large  round-celled  sarcoma,  spindle-celled  sarcoma, 
giant-celled  sarcoma  (myeloma  or  myelocytoma),  or  mixed-celled 


Fig.  127. — Small  round-celled  sarcoma.     (Microphotograph ;  X  about  100.) 

sarcoma,  in  which  there  may  appear  cells  of  the  various  types  just 
mentioned. 

Any  of  the  true  sarcomata  may  be  pigmented  or  free  from 
pigment. 

Again,  sarcomata  are  somewhat  loosely  and  incorrectly 
grouped  by  their  sites  of  origin;  hence,  osteosarcoma  or  chondro- 
sarcoma,  indicating  only  that  the  malignant  tumor  has  arisen  in 

502 


SARCOMA 


503 


B I  ood- vessels 


l-'iir.   128. — Large  round-celled  sarcoma.     (Microphotograph;  X  about  100.) 


Fig.  129. — Largo  muiid-rcHol  sarcoma  showing  nmligiumt  cells  in  lumen  of 
vessel.     (Microphotograph;  X  about  'J.">u 


504 


PRINCIPLES   OF   SURGERY 


connection  with  bone  or  cartilage,  and  not  that  these  histologic 
structures  constitute  a  part  of  the  tumor  structure. 

Lymphosarcoma  is  a  type  resembling  histologically  lymphoid 
tissue. 

Besides  the  above,  sarcoma  elements  are  often  mixed  with  other 
tumor  elements  which  give  them  a  compound  name,  the  chief  of 
which  is  perhaps  angiosarcoma. 

Etiology. — Sarcomata  arise  independently  of  any  known  cause 
and  occur  at  any  age;  they  may  be  congenital  or  arise  in  the  very 
old.  The  relationship  established  between  the  receipt  of  an  injury 


Fig.  130. — Spindle-celled  sarcoma  of  ovary,  showing  longitudinal  and  cross- 
section.     (Microphotograph;  X  about  100.) 


and  the  origin  of  sarcoma  is  very  interesting.  A  large  percentage 
of  them  develop  at  the  site  of  a  recent  or  remote  injury,  with  no 
definite  time  intervening.  The  degree  of  injury  seems  to  play  no 
important  part  in  the  etiology.  Old  inflammatory  processes,  too, 
may  serve  as  a  point  of  origin,  while  the  sudden  assumption  of 
malignant  (sarcomatous)  symptoms  by  presumably  benign  tumors 
is  a  matter  of  rather  frequent  observation.  For  instance,  I  have 
seen  a  bite,  thought  to  be  produced  by  a  mosquito,  result  in  the 
usual  red  lump,  which  failed  to  disappear  and  seemed  to  be  slightly 
inflamed,  continue  to  enlarge,  until  within  a  few  weeks  it  was  the 
size  of  a  nickel.  Upon  excision  the  microscope  showed  small  round- 


SARCOMA 


505 


" 


Fig.  131. — Large   spindle-celled   sarcoma,  show-ing   longitudinal   and   cross- 
section  of  cells.     (Microphotograph ;  X  about  250.) 


Fig.  132. — Giant-  ami  spimllt-o-llfd  sarcoma  of  biceps.     (Microphotograph; 

X  about  100.) 


506 


PRINCIPLES   OF   SURGERY 


'    '•  •      ••'      i  :  '- 


Fig.  133. — Medullary  sarcoma  of  tibia,  showing  giant  cells.     (Microphoto- 

graph;  X  75.) 


Fig.   134. — Round-celled  angiosarcoma.     Light  areas  are  the  blood  spaces. 
(Microphotograph ;  X  about  50.) 


SARCOMA 


507 


celled  sarcoma.  Another  patient  had  a  persistent  epididymitis  of 
gonococcal  origin.  During  operation  for  this  lesion  a  small  sus- 
picious-looking nodule  was  found,  which  proved  to  be  sarcoma. 
Another  case  had  been  severely  bitten  on  the  calf  of  the  leg  by  a 
sow  twenty  years  ago.  I  saw  him  some  months  after  a  tumor  had 
developed  in  the  midst  of  the  scar.  The  superficial  veins  of  the 
leg  were  markedly  varicosed.  The  tumor  was  angiosarcoma. 


Fin.   i:>"».— Trl:umi<Tt;itir  sarcoma.     Lumen  of  blood-vessels  at  *.     (Micro- 
piMtograph;  X  about  50.) 

Another,  a  woman  of  forty,  had  been  spurred  in  the  lobule  of  her 
ear  by  a  sitting  hen  ><>me  five  years  before;  she  had  a  myxosarcoma 
the  size  of  a  Malaga  grape,  al>out  the  origin  of  which  she  was  not 
clear.  Yet,  again,  a  woman  of  thirty  had  a  peduneulated  mole  of 
long  standing  on  her  neck,  which  her  physician  removed  by  liga- 
ture of  the  pedicle.  The  mole  dropped  off  and  the  stump  healed. 
In  six  months  a  tumor  had  developed  at  the  site  of  the  scar  as  large 
as  an  English  walnut;  her  condition  twelve  months  later  is  shown 


508  PRINCIPLES   OF   SURGERY 

in  Fig.  153.  Such  cases  are  so  numerous  that  there  can  be  no 
doubt  that  trauma  is  an  important,  if  only  a  predisposing,  factor 
in  the  etiology  of  sarcoma;  it  may  be  further  stated  that  trauma, 
applied  to  certain  types  of  tumors,  especially  moles  and  fibrous 
myxomata  of  the  nasal  cavity,  is  to  be  tabooed,  unless  the  whole 
growth  be  destroyed  or  removed. 

Beyond  the  effect  of  trauma  and  the  predisposition  of  certain 
benign  tumors  toward  malignancy,  the  real  unproved  cause  of 
sarcoma  remains  hidden. 

Structure. — Sarcomata  are  often  encapsulated  in  their  early 
stages  with  a  pseudocapsule;  it  is  conceivable  that  they  may  be 


Fig.  136. — Myxosarcoma.     (Microphotograph;  X  about  100.) 

» 

truly  encapsulated  at  a  very  early  stage,  but  this  cannot  be  ac- 
cepted practically  under  any  circumstances,  except  where  old 
benign  tumors  are  just  beginning  to  show  positive  microscopic 
evidence  of  malignancy.  The  guide  for  practice  is  to  be  found  in 
the  definition  of  pseudocapsule  already  given,  which  may  be 
briefly  stated  to  be  a  capsule  which  does  not  encapsulate,  and, 
therefore,  cannot  be  dealt  with  as  one  might  deal  in  positively 
benign  tumors.  One  can  never  know  if  the  tumor  cells  will  be 
found  only  in  the  wall  of  a  pseudocapsule  or  beyond  it,  and  how 
far  beyond. 

On  the  other  hand,  sarcoma  may  show  no  evidence  at  en- 


SARCOMA 


509 


Pig.  137. — Lymphosarcoma.     (Microphotograph;  X  about  100.) 


f. 


Fig.  138. — Lymphosarcoma.     (Microphotograph;  X  about  250.) 


510  PRINCIPLES   OF   SURGERY 

capsulation,  and  invade  the  tissues  in  contact  with  it  in  any  or 
every  direction.  It  is  of  value  to  note  here,  however,  that  sarco- 
mata do  not  infiltrate  habitually  as  readily  or  as  extensively  as 
carcinomata  do. 

The  structure  of  sarcoma  may  be  briefly  said  to  be  a  mass  of 
"embryonic"  mesoblastic  cells  of  new  formation,  held  in  place  by 
a  cement  (intercellular)  substance  supplied  with  little  connective 
tissue  and  with  numerous  blood-vessels,  whose  walls  are  so  poorly 
developed  as  to  escape  observation  very  often,  thus  bringing  the 
cells  of  the  tumor  in  almost  direct,  if  not  direct,  contact  with 
the  circulating  blood. 


Fig.  139. — Melanoma;   X  about  15.     The  black  areas  represent  pigment; 
this  is  through  entire  section. 

The  bulk  of  sarcomatous  tissue  is  made  up  of  malignant  cells. 
Portions  of  tissue  which  have  been  invaded  may  be  found  incor- 
porated in  the  tumor  mass,  usually  in  an  atrophic  or  degenerative 
state.  The  cells  show  no  definite  arrangement,  and  develop  about 
the  new  capillary  loops  that  form  in  the  growing  portion  of  the 
tumor.  The  intercellular  cement  substance  is  usually  of  mucous 
or  fibrillar  form,  although,  when  the  tumor  arises  from  osseous  or 
cartilaginous  analgen,  it  may  be  bone  or  cartilage. 

The  vessels  of  sarcomata  are  poorly  developed,  being  repre- 
sented by  a  lining  of  endothelium  resting  directly  upon  the  sur- 
rounding cellular  walls.  In  other  instances  they  may  be  sup- 
ported by  a  variable  supply  of  connective  tissue.  The  vessels  are 


SARCOMA  511 

relatively  numerous,  and  are  often  more  like  caverns  than  ordinary 
vessels.  When  they  are  especially  abundant  the  tumors  are  called 
angiosarcomata  or,  preferably,  telangiectatic  sarcomata. 

The  structure  of  the  various  types  of  sarcomata  demands  dis- 
cussion somewhat  in  detail. 

Melanotic  sarcomata  (or  melanocarcinomata,  as  some  eminent 
pathologists  call  them)  are  peculiar  in  respect  both  of  pigment  and 
structure,  two  facts  which  have  indicated  their  possible  deriva- 
tion from  epiblastic,  instead  of  mesoblastic,  cells.  Melano- 
sarcomata  are  discolored  by  the  presence  of  pigment  in  their 
cell.-.  The  color  varies  from  brown  to  black,  and  may,  to  the  naked 


Fin.  140. — Melanoma;  X  about  250.     Melanin  granules  in  the  cells  at  (z) ;  in 
the  connective  tissue  at  (o). 

eye,  appear  uniformly  distributed  throughout  the  tumor  or  irregu- 
larly distributed,  showing  on  section  a  uniform  or  mottled  black 
or  brown  cut  surface.  On  microscopic  examination  the  cells  are  of 
variable  shape — spindle,  round,  and  irregular  cells  all  showing. 
The  tumor  is  seen  to  be  divided  into  alveoli,  through  the  frame- 
work of  which  the  rin-ulation  is  conveyed.  The  pigment  is  dis- 
tributed in  the  protoplasm  of  the  cells  in  the  form  of  minute  gran- 
ules, which  are  found  more  abundantly  or  solely  in  those  cells 
nearest  the  alveolar  partitions. 

Lymphosarcomata  are  so  named  because  of  the  similarity  exist- 
ing between  their  structure  and  that  of  lymph-nodes  or  other 
lymphatie  t'<sue.  and  because  they  develop  from  lymphatic  tissue, 


512  PRINCIPLES   OF   SURGERY 

from  which  they  can  sometimes  be  distinguished  only  with  great 
difficulty.  They  are,  therefore,  characterized  by  a  connective- 
tissue  reticulum,  the  quantity  of  which  is  variable,  with  a  conse- 
quent variation  hi  the  hardness  of  the  tumor,  and  of  cells  held 
in  position  by  the  reticulum.  The  cells  also  closely  resemble  the 
white  blood-corpuscles  and  the  lymphatic  corpuscles. 

Myxosarcomata  are  literally  a  mixed  form  of  sarcoma,  in 
which  there  is  a  variable  abundance  of  mucoid  tissue.  The 
sarcoma  cells  are  of  the  polymorphous  type,  with  occasional 
giant  cells,  with  long  processes  extending  from  them.  The  myx- 


Fig.  141. — Melanosarcpma  of  popliteal  space.     Note  small  metastases  sur- 
rounding primary  large  growth.     (Almost  natural  size.) 

omatous  portion  may  appear  as  a  homogeneous  mass  or  be  pro- 
vided with  a  small  quantity  of  fibrillar,  tissue.  Sometimes  the 
intercellular  substance  presents  a  granular  appearance. 

It  will  be  seen  from  the  above  that  the  commonly  employed 
nomenclature  of  sarcomata  is  somewhat  at  variance  with  the 
usage  in  other  tumors.  For  example,  adenomyoma  means  a 
tumor  made  up  of  glandular  and  muscular  tissue.  On  the  con- 
trary, osteosarcoma  signifies  sarcoma  arising  from  bone,  whether 
the  tumor  itself  contains  bony  elements  or  not;  chondrosarcoma 
similarly  means  sarcoma  arising  from  cartilage.  Lymphosarcoma 
is  one  containing  lymphoid  elements;  angiosarcoma  is  usually 


SARCOMA 


513 


employed  to  represent  sarcoma  telangiectodes.     Myxosarcoma 
possibly  represents  a  true  mixture  of  tumor  elements. 


Fig.  142. — Enormous  mediastinai  lymphosarcoma. 

The  consistence  and  the  cut-surface  appearance  of  sarcomata 
is  of  great  importance  from  a  pathologic  standpoint.  Like  other 
tumors,  it  will  be  understood  that  the  greater  the  cellular  content 
and  tli<-  less  stroma,  the  softer  the  tumor  will  be,  provided  the 


Fin.  1  to.     Myxosarcoma  of  tibia, 


n-s.-i-t,-,l  ix.rtion  of  bone. 


tumor  is  not  a  myxosarcoma;  here,  of  course,  tin-  greater  the  pro- 
portion of  myxomatous  tissue,  the  softer  the  tumor  will  be.  The 
supposition  that  an  oMeo-armnia  ami  ehondrosarcoma  contain 
bone  and  cartilage  respectively  has  led  to  an  unfounded  l.elief  that 
3:1 


514  PRINCIPLES   OF   SURGERY 

such  tumors  are  necessarily  hard  tumors,  whereas  the  very  name 
sarcoma  signifies  a  fleshy,  and,  therefore,  a  more  or  less  soft 
tumor;  and  if  these  classes  are  occasionally  hard  it  is  not  to  be 
concluded  that  they  are  universally  so.  Sarcomata  are  often  so 
soft  as  to  be  distinctly  fluctuant;  this  is  especially  so  if  hemorrhage 
has  escaped  into  the  tumor  substance  or  if  cysts  have  developed 
within  it. 

The  cut  surface  of  sarcoma  is  often  so  characteristic  as  to  render 
microscopic  examination  almost  superfluous.  The  color  is  gray  or 
grayish  red,  or  distinctly  red  if  there  has  been  abundant  hemor- 
rhage into  the  tumor  substance.  The  surface  usually  has  a  sug- 
gestion of  translucency.  Punctate  hemorrhagic  spots  may  often 
be  seen  distributed  over  the  surface,  and  often  large  quantities  of 
blood  may  be  encountered.  This  is  especially  true  of  the  softer, 


Fig.  144. — Sarcoma  of  axilla  of  ten  months'  duration.     Inoperable. 

rapidly  growing  tumors.  Sarcomata  are  usually  cut  with  ease,  and 
many  are  so  fragile  as  to  be  torn  to  pieces  as  easily  as  necrotic 
tissue.  The  consistency  of  myxosarcoma  and  of  old  degenerating 
portions  of  other  sarcomata  is  that  of  soft  gelatin. 

Sites  of  Formation. — Since  sarcomata  are  mesoblastic  tumors, 
it  follows  that  they  can  develop  only  from  those  tissues  derived 
from  this  embryonic  layer.  There  are,  however,  as  a  matter  of 
fact,  only  a  few  of  the  mesoblastic  histologic  tissues  which  afford 
origin  to  malignant  tumors.  They  all  belong  to  the  connective- 
tissue  framework,  with  the  exception  of  the  lymphatic  tissues. 
By  far  the  majority  of  sarcomata  arise  from  the  connective-tissue 
proper,  whether  it  be  from  cellular  tissue,  aponeuroses,  tendons 
and  tendon  sheaths,  or  skin.  Next  come  those  which  originate 
in  bone  or  periosteum  (myeloid  and  periosteal  sarcomata),  and 
last  those  derived  from  lymphatic  tissue.  This  statement  holds 


SARCOMA 


515 


true,  whether  malignant  gliomata  are  admitted  into  the  class  with 
sarcomata  or  not,  inasmuch  as  the  glia  serves  as  a  connective  tissue 
to  the  central  nervous  system. 


I  ML'.  145. — Recurrent  cystic  sarcoma  of  the  thigh. 


i'in.  1  l(l      "I'll"  satin-  tumor  after  removal,  showing  cavity  of  cyst. 

Furthermore,  when  benign  tumors  become  sarcomatous,  it  is 
by  virtue  of  changes  in  the  cells  of  their  connective-tissue  content 


516  PRINCIPLES   OF   SURGERY 

and  not  in  the  more  highly  specialized  cells.  An  exception  to  the 
broad  statement  must  be  made  relative  to  malignant  (sarcoma- 
tous?)  hypernephromata,  which  originate  from  misplaced  rests  of 
adrenal  tissue. 

Sarcomata  of  the  Skin. — Sarcomata  appear  as  congenital  tumors 
of  the  skin,  as  independent  tumors  acquired  at  any  age  with  or 
without  a  history  of  trauma,  and  as  secondary  changes  in  the  most 
common  benign  tumors  affecting  this  membrane,  namely,  moles, 
whether  pigmented  or  not,  and  occasionally  from  vascular  nevi, 
especially  the  pigmented  variety.  The  skin  affords  the  greatest 
number  of  pigmented  sarcomata;  and  they  are  especially  likely  to 
arise  from  moles  or  flat  pigmented  nevi,  although  pigmented  sar- 


Fig.  147. — Sarcoma  of  base  of  skull  protruding  into  orbit. 

comata  do  not  all  have  such  antecedents.  The  majority  of  skin 
sarcomata  are  secondary  to  moles,  and  are  more  likely  to  develop 
if  the  mole  has  been  injured,  irritated,  or  imperfectly  removed. 
Sarcomata  of  the  skin  arise  from  the  cutis  or  subcutis,  and  while 
they  are  usually  spindle  celled  and  firm,  the  larger  and  longer  the 
cells,  the  firmer;  however,  large  or  small  round-celled  sarcomata 
are  seen,  and  are  softer  than  the  spindle-celled  tumors.  The 
large  round-celled  tumors  sometimes  present  a  distinct  alveolar 
arrangement. 

In  skin  sarcomata  mixed  forms  are  sometimes  observed; 
fibrosarcoma,  in  which  fibrous  tissue  is  abundant,  although  it  is 
not  unusual  for  a  moderate  quantity  of  fibrous  tissue  to  be  present; 


SARCOMA 


517 


myxosarcoma,  of  which  the  majority  occur  in  very  young  children; 
:in<l  anjjiosarcoma,  which  appears  as  a  firm  or  soft  tumor,  depend- 
ent upon  the  relative  quantity  of  sarcomatous  and  vascular  tissue. 
Vascular  (angio-)  sarcomata  may  develop  rarely  from  angiomata, 
but,  as  a  rule,  they  grow  slowly  and  fail  to  give  one  the  impression 
of  malignancy  unless  they  are  pigmented.  Another  tumor  of  the 
skin  should  be  recalled  here,  namely,  lymphendothelioma,  which 
arises  from  the  endothelial  cells  of  the  lymph-vessels,  but  cannot 
be  distinguished  clinically  from  sarcoma.  Kaposi  has  called 
attention  to  a  condition  which  he  designates  idiopathic  multiple 
pigmented  sarcoma  of  the  skin.  It  is  at  present  not  thought  to  be 


.  14s.  —  Sarcoma  of  breast  in  an  old  man. 


sarcomatous,  as  it  may  persist  many  years  and  disappear  without 
treatment;  sometimes  the  nodules  do  unquestionably  become 
malignant 

Sarcomata  of  the  skin  appear  as  roundish.  -mouth  tumors  with 
variable  tendency  to  lobulation,  and  are  usually  sessile,  though 
they  may  be  pedunculated. 

Secondary  sarcomata  of  the  skin  may  be  seen  in  any  metastas- 
inu  >arc<»ma.  but  are  especially  likely  to  follow  ostoosarcoma  or 
intestinal  sarcoma 

Coniudnr  Tissue  and  Fascia.  —  It  is  readily  understood  that 
sarcomata,  which  are  connect  ive-tis>ue  tumors,  should  originate 
from  connective  ti—  ue  in  the  majority  of  cases;  and  with  the  ex- 


518 


PRINCIPLES    OF   SURGERY 


ception  of  lymphosarcomata  we  may  accept  as  true  the  statement 
that  all  sarcomata  do  arise  from  connective  tissue,  and  that  when 
a  sarcoma  originates  hi  an  organ  whose  chief  structure  is  paren- 
chyma we  may  be  sure  the  malignant  growth  found  its  origin  not 
in  the  functionating  specialized  cells,  but  in  the  supportive  stroma. 
The  discussion  of  sarcoma  of  connective  tissue  and  fascia  is  not 
intended,  therefore,  to  leave  the  impression  that  this  type  of 
malignant  tumor  arises  from  other  sources.  In  the  subcutaneous, 
submucous,  and  intermuscular  connective  tissue,  in  the  aponeuro- 
ses  and  the  adipose  layers,  hi  tendons  and  bursae,  hi  the  periosteum 
(which  will  be  discussed  with  sarcoma  of  bone  and  periosteum) 


•*  .  <~"    ,  „        _^&w. 


Fig.  149. — Myxo-lipo-sarcoma;  X  about  100. 

sarcomata  find  their  origin  very  frequently,  and  rarely  from 
vascular  sheaths  and  the  retroperitoneal  connective  tissue. 

Sarcoma  of  the  intermuscular  fascia  and  aponeuroses  develops 
with  far  greater  frequency  between  the  large  muscles;  the  sites  most 
commonly  affected  being  the  hip  and  upper  thigh,  the  shoulder, 
arm  and  neck,  the  abdomen,  and  the  leg. 

Bone  and  Periosteum. — The  term  "osteosarcoma"  has  very  un- 
fortunately crept  into  the  literature  of  tumors,  and  is  used  to  signify 
a  sarcoma  which  originates  from  bone  regardless  of  the  structure  of 
the  tumor.  It  is  better,  I  believe,  to  dispense  with  the  term  here 
to  avoid  confusion,  under  the  two  headings  of  myelogenous  sar- 


SARCOMA 


519 


coma  of  the  bone  and  periosteal  sarcoma  of  the  bone,  for  while  it 
may  be  more  pertinent  from  a  histologic  standpoint  to  discuss 
periosteal  sarcoma  in  conjunction  with  those  arising  from  the 
fibrous  connective-tissue  fascia,  there  can  be  no  question  as  to  the 
practical  value  of  the  adopted  arrangement. 

Myelogenous  sarcoma  of  bone  may  be  found  appearing  in  con- 
nection with  any  bone  of  the  body;  it  appears  by  preference  in 
certain  very  definite  bones,  of  which  the  jaws,  more  especially  the 
lower  jaw,  head  the  list;  it  appears  with  great  frequency  also  in  the 
epiphyses  of  the  long  bones,  rarely  in  the  diaphysis.  The  long 
bones  most  frequently  affected  are  the  tibia,  and  then  the  radius 

Cartilage 


Bone. 


Fig.  150. — Osteochondrosarcoma.     (Microphotograph ;  X  about  100.) 


and  the  ulna.  Myelogenous  tumors  are  of  various  structures, 
small  or  large  round  celled,  spindle  celled,  or  mixed.  They  often 
show  great  numbers  of  giant  cells.  The  cells  may  assume  an 
aveolar  arrangement,  like  carcinoma. 

The  periosteal  sarcomata  of  bone  originate  chiefly  in  the  ends 
of  the  long  bones,  but  may  occasionally  be  seen  on  any  part  of 
the  skeleton.  They  are  round-,  spindle-,  and  mixed-celled  tumors 
with  giant  cell-  showing  occasionally. 

Lymphatics.— Round-celled,  spindle-celled,  and  pigmented  or 
angiosnreomuta  arc  rarely  observed  as  primary  sarcomata  of  the 
lymph-nodes  and  when  they  do  arise  from  them  they  are  in  ap- 


520  PRINCIPLES   OF   SURGERY 

pearance  the  same  as  usual,  and  identical  in  origin,  arising,  namely, 
from  the  connective  tissue. 

There  is,  however,  a  peculiar  form  of  sarcoma  whose  con- 
nection with  the  lymphatic  structures  of  the  body  is  very  intimate 
and  whose  behavior  is  peculiar,  viz.,  lymphosarcoma.  The  name 
is  applicable  because  the  structure  of  the  tumor  microscopically 
resembles  that  of  lymph-nodes  so  closely  that  frequently  it  is 
necessary  to  invoke  the  clinical  history  to  settle  their  true  nature, 
unless  the  section  examined  be  obtained  from  an  infiltrating  border; 
the  name  applies  as  well  because  of  the  fact  that  these  tumors  are 
thought  to  arise  from  lymphoid  tissue,  wherever  it  may  be  found. 


Fig.  151. — Lower  jaw  resected  for  sarcoma,  showing  tumor  and  pathologic 

fracture. 

There  are  two  types  of  lymphosarcoma — localized  and  general. 
The  former  is  far  the  more  common  and  occurs  with  greatest  fre- 
quency in  the  neck,  the  mediastinum,  the  mesentery,  and  the  retro- 
peritoneal  lymph-nodes,  in  all  of  which  except  those  from  the 
thymus  -they  produce  multiple  and  enormous  enlargement  of  the 
nodes.  The  lymphoid  tissue  of  the  throat  and  the  gastric  and  in- 
testinal mucosa  also  serve  as  starting-points. 

The  diffuse  or  general  type  is  far  less  common.  It  may  arise 
from  any  lymphoid  tissue  and  produce  a  general  metastasis,  in 
contrast  with  the  localized  growth  of  multiple  tumors  in  the 
regional  type. 

Nervous  System. — The  central  nervous  system,  more  especially 
the  brain,  may  be  occasionally  the  starting-point  of  primary  sarco- 


SARCOMA 


521 


mata,  that  is,  they  may  originate  from  the  stroma  of  these  struc- 
tures; they  are  much  more  frequently  affected  by  sarcomata  which 
have  developed  from  their  meninges,  the  bony  walls  surrounding 
them,  or  the  periosteum  covering  this 
bone.  The  tumors  are  usually  either 
spindle  or  mixed  celled. 

The  nerves  are  occasionally  the 
source  of  sarcomata,  and  the  types 
usually  found  are  spindle-celled  and 
myxosarcomata.  Sarcomata  of  the 
nerves  are  produced  in  consequence 
of  malignant  change  of  pre-existing 
benign  tumors,  one-twelfth  of  all  cases 
of  multiple  fibromata  dying  ultimately 
of  sarcoma  (Bruns). 

Alimentary  Tract. — Sarcomata  of 
the  esophagus  and  stomach  are  seldom 
seen.  They  may  in  either  situation 
arise  as  primary  tumors  or  in  conse- 
quence of  malignant  changes  in  benign 
tumors.  In  the  stomach  they  usually 
arise  from  the  submucosa  or  the  mus- 
cular layer  (or  subserosa),  and  rarely 
from  the  mucous  membrane. 

The  intestine  is  likewise  rarely  af- 
fected by  primary  sarcoma,  and  the 
cecum  and  lower  ileum  are  the  parts 
most  frequently  attacked.  The  tumors 
are  round-  or  spindle-celled  and  may 
be  alveolar. 

The  rectum  rarely  is  affected  by 
sarcoma,  but  it  may  be;  and  rectal 
sarcomata  are  sometimes  melanotic. 
Sarcomata  of  the  intestines  occur  much 
more  frequently  (three  times)  in  males 

than  in  females.      Lymphosarcoma  shows  a  predilection  for  the 
intestines  and  may  be  primarily  multiple. 

l.'i'cr. — This  organ  rarely  serves  as  the  site  of  origin  of  primary 
sarcoma,  being  much  more  frequently  affected  by  secondary 
tumors.  However,  reports  of  many  types  of  sarcoma — round-, 
spindle-,  giant-celled,  and  angiosarcoma — have  been  made. 

The  pancreas  and  spleen  an-  rarely  affected  by  primary  sarco- 
mata. 

Ovaries. — Sarcoma  of  the  ovaries  occurs  with  moderate  fre- 
quency, and  is  often  found  attacking  both  ovaries  at  the  same 


Fig.  152.  — Spindle-celled 
sarcoma  affecting  the  radius 
and  the  ulna. 


522 


PRINCIPLES   OF   SURGERY 


time.  The  tumors  are  spindle-celled  usually;  however,  mixed- 
celled,  round-celled,  giant-celled,  and  myxosarcomata  are  some- 
times found.  In  addition,  there  occur  tumors  which  appear  to  be 


IBI 

Fig.  153. — Sarcoma  of  neck  resulting  from  ligation  of  a  pedunculated  mole. 


I 


Fig.  154. — Sarcoma  of  lower  jaw  in  a  child  whose  permanent  incisors  are  just 
beginning  to  erupt. 

mixed,  such  as  perithelioma  mixed  with  endothelioma,  sarcoma 
and  carcinoma,  or  sarcoma  with  adenoma  or  cystadenoma.  A 
few  melanosarcomata  of  the  ovary  have  been  reported. 


SARCOMA  523 

Uterus. — Sarcoma  of  the  uterus  may  develop  as  a  primary 
tumor  or  as  a  malignant  transformation  of  fibromyomata.  In 
the  corpus  they  originate  from  connective  tissue  or  the  blood- 
vessels of  the  endometrium,  or  from  the  myometrium.  Cervical 
sarcomata,  though  less  frequent  than  those  in  the  body,  may  ap- 
pear in  bunches  or  in  the  form  of  polypi.  Sarcomata  of  the  uterus 
an-  usually  round-  or  spindle-celled  or  the  two  mixed.  Giant 
cells  are  sometimes  found.  The  cervical  variety  are  frequently 
lymphangiectatic  spindle-celled  tumors,  and  they  may  be  myxoma- 
tous  or  edematous.  Sarcoma  and  carinoma  are  rarely  found  grow- 


Fig.  155. — Sarcoma  of  testicle. 

ing  synchronously  in  the  same  uterus,  or  they  may  appear  as 
mixed  tumors,  sarcocarcinoma,  hi  which  it  is  stated  that  the 
Mmma  of  a  cracinoma  has  undergone  sarcomatous  change. 

T>  xticles. — As  hi  the  ovaries,  so  here  the  tumor  may  originate 
either  as  a  unilateral  or  bilateral  affliction;  they  may  appear  very 
early  in  life,  ;uul  in  any  age  usually  arise  from  the  testicle  proper. 
The  extension  of  the  tumor  l>y  infiltration  through  the  testicular 
coverings  re-ulte  in  a  fungoid  ulcer  known  as  fungus  sarcomatodes. 
The  same  confusion  of  cell  types  is  found  here  as  hi  the  ovaries, 
although  the  round-  and  spindle-celled  varieties  predominate. 
Pigmented  sarcoma  is  rare.  Adenosarcoma  and  sarcocarcinoma 


524  PRINCIPLES   OF   SURGERY 

are  very  rarely  observed.    Sarcomata  of  the  testicles  very  often 
contain  glycogen. 

Diagnosis  of  Sarcoma  in  General. — Under  this  caption  it  is 
necessary  to  call  attention  to  the  fact  that  many  of  the  notions 
held  by  some  of  the  profession  are  due  to  ancient  teachings  that 
have  been  handed  down  from  generation  to  generation,  without  an 
attempt  to  correct  them  in  accordance  with  the  advances  made  by 
pathologic  study  and  clinical  observation  of  patients  before  and 
after  treatment,  and  by  our  ability  to  make  accurate  diagnosis 
microscopically  long  before  a  clinical  diagnosis  could  be  vouch- 
safed. Hence,  much  that  is  untrue  is  still  accepted  and  occa- 
sionally acted  upon  as  true. 


Fig.  156. — Sarcoma  removed  from  labium  majus,  showing  capsule  dissected 

back. 

Before  discussing  the  subject  in  detail  it  is  perhaps  wise  to  give 
a  condensed  statement  of  the  diagnostic  features  of  sarcoma. 
Sarcoma  arises  from  mesoblastic  structures,  and  may,  therefore, 
appear  either  as  a  very  superficial  or  deep  tumor.  In  a  con- 
siderable percentage  of  cases  there  is  a  history  of  trauma  or  of  a 
benign  tumor.  Sarcoma  is  usually  a  rapidly  growing  tumor,  and 
the  assumption  of  a  malignant  change  on  the  part  of  benign 
tumors  is  to  be  suspected  when  they  begin  to  grow  rapidly  after 
a  prolonged  period  of  slow  increase  in  size  or  of  quiescence.  They 
grow  as  more  or  less  spheric  tumors  when  small,  but  are  often  nodu- 
lar or  lobulated  when  large,  and  are  caused  to  deviate  from  the 
spheric  shape  by  the  influence  of  their  environment.  They  are 
usually  firm,  flesh-like  tumors,  or  may  be  so  soft  and  fluctuant  as  to 
lead  to  the  diagnosis  of  abscess;  on  the  other  hand,  they  may  be 


SAK<  «>MA 


525 


extremely  hard.  Sarcomata  are  often  pseudo-encapsulated  and  are 
thus  as  movable  as  if  they  were  benign;  as  a  rule  they  are  less 
likely  to  become  fixed  by  infiltration  and  to  mat  various  layers  of 
tissue  together  than  carcinomata.  Lymph-node  involvement  does 
not  occur  except  in  rare  instances,  as  in  the  tonsil  and  the  testicle. 
The  age  of  sarcoma  patients  varies  from  the  unborn  fetus  to  the 
octogenarian,  and  it  is  probable  that  the  majority  occur  in  the 
most  active  years  of  life,  between  the  ages  of  fifteen  and  fifty  years. 
The  idea  that  sarcoma  is  found  most  frequently  in  the  young  has 
long  been  disproved.  Pain,  as  a  rule,  is  absent,  and  comes  only 
after  the  tumor  has  reached  a  rather  advanced  development,  when 


—Sarcoma  of  superior  maxilla. 


by  its  size  or  location  it  causes  pain,  frequently  just  as  a  benign 
tumor  similarly  situated  would.  The  presence  of  pain  has  some 
diagnostic  value,  its  absence  in  tumors  means  nothing.  Fever 
is  occasionally  promt,  especially  in  advanced  sarcoma  of  the 
vi-cera.  ;m<l  may  lead  to  the  suspicion  of  malaria  or  a  low-grade 
infection.  The  general  effect  of  the  tumor  is  to  produce  cachexia, 
hut  it  i>  not  :in  unusual  thing  to  find  even  large  sarcomata  with  little 
or  no  evidence  of  cMchexia.  provided  no  complications — especially 
ulceration.  infection,  or  hemorrhage — have  occurred. 

History. — The  question  of  hereditary  influence  in  the  produc- 
tion of  sarcoma  i-  of  no  demon-traMe  importance  and  may  be  dis- 
carded. However,  it  is  of  extreme  importance  to  know  that  the 


526  PRINCIPLES    OF   SURGERY 

tumor  has  arisen  at  the  site  of  a  previous  injury,  and  the  tumor  may 
begin  to  develop  immediately  and  grow  with  astonishing  rapidity, 
or  its  appearance  may  be  delayed  for  an  indefinite  time.  The 
nature  of  the  injury  or  its  degree  seems  to  have  little  to  do  with 
the  case.  Sarcomata  arise  from  great  or  small  injuries,  and  if  there 
is  any  difference,  it  is  in  favor  of  minor  injuries.  The  fact  that  a 
tumor  has  been  present  for  a  number  of  years  is  most  important, 
although  its  clinical  course  has  led  to  a  conclusion  that  it  was 
benign.  When  an  accelerated  rate  of  growth  takes  place  in  such  a 
tumor  it  is  of  the  highest  evidence  that  it  has  become  malignant; 
the  evidence  is  intensified  if  the  "benign"  tumor  was  of  a  type 
prone  to  become  sarcomatous,  especially  moles,  myxomata,  and 
fibromata,  and  if  it  has  previously  been  injured  or  incompletely 
removed. 

Age. — It  is  of  no  importance  to  consider  the  age  of  a  patient 
in  cases  of  sarcoma,  except  in  so  far  as  the  age  may  render  it  neces- 
sary to  differentiate  between  this  and  other  tumors,  especially 
carcinomata,  for  sarcoma  is,  above  all,  a  tumor  affecting  all  ages. 
It  may  be  congenital  or  occur  at  any  time  thereafter.  Rodman 
found  the  average  age  for  spindle-celled  sarcoma  of  the  breast 
to  be  36f  years,  and  of  round-celled  sarcoma,  47|  years.  I  have 
personally  seen  many  more  cases  of  sarcoma,  generally,  occurring 
in  the  middle  aged  than  in  the  young. 

Mode  and  Rate  of  Growth. — By  close  observation  of  an  actively 
growing  sarcoma  for  a  period  of  a  few  weeks  a  very  important  idea 
of  its  nature  may  be  gathered.  The  question  as  to  what  consti- 
tutes a  rapidly  growing  tumor  and  what  a  slowly  growing  tumor 
cannot  be  dogmatically  stated.  Besides,  there  are  benign  tumors 
which  grow  relatively  fast,  and  malignant  tumors  growing  rela- 
tively slow.  The  best  rule  to  follow  is  to  consider  all  tumors 
growing  suspiciously  as  malignant,  unless  they  can  be,  or  until 
they  shall  have  been,  demonstrated  to  be  benign. 

I  have  stated  already  that  sarcomata  tend  to  grow  in  the  shape 
of  a  sphere,  yet  when  they  are  surrounded  by  large  muscles  or 
bone  they  are  more  or  less  flattened  or  distorted  by  pressure. 
Sarcomata  are  sometimes  pedunculated,  e.  g.,  those  arising  from 
the  cervical  canal. 

The  growth  is  most  rapid  along  the  lines  of  least  resistance. 
Hence,  when  the  tumor  is  situated  primarily  in  a  bony  cavity, 
processes  of  tumor  tissue  may  protrude  through  apertures  and 
cause  apparent  secondary  growths  in  an  adjacent  cavity  or  on  the 
outer  surface  of  the  bone.  The  process  leading  from  the  first  to  the 
second  nodule  may  be  so  attenuated  as  to  escape  observation,  and 
such  outgrowths  are  often  the  cause  of  return  of  the  tumor  in  the 
same  region.  The  tendency  for  sarcomata  to  occur  in  the  form  of  a 


SARCOMA  527 

large  primary  tumor  more  or  less  surrounded  by  smaller  nodules 
is  very  important,  and  is  probably  due  to  extension  in  the  manner 
just  described. 

Size. — The  ultimate  size  obtained  by  sarcomata  is  limited,  it 
would  seem,  only  by  the  death  of  the  patient.  It  is  not  unusual  to 
find  tumors  as  large  as  a  child's  head  and  sometimes  as  large  as  an 
adult's  head.  I  have  removed  a  spindle-celled  sarcoma  of  the 
uterus  which  weighed  13  pounds.  The  largest  tumors  are  prob- 
ably those  arising  from  the  kidneys  and  the  retroperitoneal  space. 


ig.  168.  —  Pigmcnted  sarcoma  of  the  foot. 


Surface  Appearance.  —  In  superficial  sarcomata,  especially 
tin  or  <>t  the  skin  and  all  those  which  have  grown  close  to  it  by  in- 
filtration from  deeper  structures,  the  surface  may  or  may  not  ap- 
pear red,  as  if  an  inflammatory  process  were  present.  This,  of 
course,  depends  on  the  extent  of  skin  involvement  and  the  circula- 
tion present.  The  skin  usually  appears  normal  until  infiltration 
has  taken  place,  and  is  altered  only  in  consequence  of  the  stretch- 
ing produced.  In  superficial  or  deep  sarcomata  the  subcutaneous 
vein-  overlying  the  tumor  are  often  enlarged  as  compared  with 
those  of  the  opposite  side.  The  tumor  may  pulsate  or  give  rise  to 
a  purring  sound,  a  kind  of  bruit,  from  the  excess  of  circulation. 


528 


PRINCIPLES   OF   SURGERY 


It  is  important  to  state  in  this  connection  that  a  very  valuable 
evidence  of  malignancy  can  be  discovered  at  times  by  examining 
the  surrounding  tissues  for  evidence  of  an  increased  arterial  flow, 
which  adjusts  itself  in  case,  for  example,  of  uterine  sarcoma  just 
as  in  cases  of  pregnancy.  So,  too,  in  malignant  tumors  of  the 
bladder  enlarged  arteries  may  often  be  palpated  per  vaginam. 

Myxosarcomata  of  the  skin  may  be  translucent,  and  pigmented 
sarcomata  naturally  brown,  black,  or  mottled. 

Consistency. — This  factor  may  be  said  to  vary  throughout  the 
range  of  possibilities.  A  sarcoma  is  usually  a  moderately  firm 


Fig.  159. — Pigmented  sarcoma  of  thigh,  which  grew  from  size  of  a  grain  of 
corn  in  two  months  following  an  injury.    Observe  enlarged  inguinal  node. 

tumor  of  flesh-like  consistency,  firmer  than  relaxed  muscle  or  than 
a  lipoma.  In  certain  instances,  namely,  the  myxosarcomata  and 
the  hyperacute  sarcomata,  they  may  be  as  soft  as  a  cold  ab- 
scess, and  are,  indeed,  mistaken  for  collections  of  fluid.  When 
the  sarcoma  is  cystic  or  when  recent  abundant  hemorrhage 
into  the  tumor  mass  has  occurred  the  tumor  becomes  distinctly 
fluctuant,  and  it  is  different  from  a  cyst  in  feel  only  by  the  thick- 
ness of  its  walls,  which  may  be  variable,  if  palpable.  On  the  other 
hand,  the  tumor  may  appear  as  firm  as  a  fibroid,  and  from  its 
physical  appearance  be  indistinguishable  from  it.  It  may  be  even 


SARCOMA  529 

harder  and  give  evidence  of  being  osseous  or  cartilaginous,  al- 
though it  must  not  be  concluded  that  all  osteo-  and  chondro- 
san ••iiuata  are  of  this  consistency. 

From  the  above  statements  it  becomes  clear  that  there  are  no 
uniform  standards  for  the  consistency,  such  as  are  found  in  lipoma, 
for  instance,  and  that  while  it  may  resemble  any  tumor  in  this 
respect,  other  factors  must  be  employed  to  determine  its  true 
nature. 

Encapsulation  and  Mobility. — The  capsule  of  some  sarco- 
mata is  so  perfect  that  they  may  be  easily  enucleated  from  their 
bed  (Fig.  156).  Others  show  no  effort  at  encapsulation  and  be- 
have malignantly  from  the  outset.  All  lose  their  encapsulation  at 
some  time  by  infiltration  through  its  walls,  and  usually  ultimately 
destroy  all  vestiges  of  it.  So  long  as  the  tumor  is  encapsulated,  if 
it  is  at  all,  it  deports  itself  as  an  encapsulated  benign  tumor. 
Malignancy  and  benignity  have  nothing  to  do  with  the  mobility 
of  a  tumor  hi  its  early  development,  but  this  is  determined  by  the 
pre>ence  of  a  capsule,  which  separates  it  in  a  gross  way  from  the 
surrounding  tissues.  This  is  exceedingly  important,  for  the  fre- 
quent encapsulation  and  free  mobility  of  sarcomata  hi  their  earlier 
stages  cause  the  unwary  to  render  a  hasty  diagnosis  of  innocency, 
and  to  allow  the  golden  time  of  safety  to  escape.  There  are  certain 
tumors  which  grow  slowly  for  a  tune,  are  unquestionably  encap- 
sulated and  movable,  which  when  they  escape  their  capsule  assume 
the  role  of  violent  malignancy,  so  that  the  question  has  been 
rai-cd  whether  they  were  benign  tumors  from  the  beginning,  or 
only  malignant  tumors  behaving  benignly  for  the  tune.  From 
a  practical  standpoint  it  would  be  better  to  consider  that  the  tumor 
\\a>  malignant  from  the  beginning,  unless  all  were  fully  aware 
that  practically  every  tumor  should  be  considered  a  menace  to  the 
life  of  its  host,  whether  at  present  it  is  malignant  or  not. 

Infiltration  and  Immobility. — While  sarcoma  is,  as  a  rule,  more 
frequently  movable  and  longer  movable  than  carcinoma,  it  must 
be  impressed  that  all  sarcomata  do  infiltrate  the  surrounding  tis- 
sues, in  many  cases  even  from  the  beginning.  The  growth  of  the 
tumor  into  surrounding  tissues  causes  degeneration,  disintegration, 
and  loss  of  function,  and  the  presence  of  the  tumor-cells  in  a  muscle, 
for  instance,  may  be  recognized  among  the  muscle-fibers  by  the 
microscope  or  even  by  the  naked  eye.  Certain  structures  are  less 
Hal )!••  to  infiltration,  chief  of  which  may  be  named  lymph-nodes, 
which  may  l»e  found  sometimes  completely  ensheathed  in  the 
sarcoma  mass,  but  showing  no  invasion  of  their  substance,  car- 
tilage, and  s\  novial  membranes,  the  exception  of  which  constitutes 
remarkable  pathologic  phenomena:  the-e  two  last  statements  are 
illustrated  by  the  infrequency  with  which  sarcomata  of  bone  invade 

34 


530  PRINCIPLES   OF   SURGERY 

the  epiphyseal  cartilages,  and  the  rare  invasion  of  a  joint  cavity  by 
a  sarcoma  lying  close  to  it.  Blood-vessels  form  no  exception  in  the 
infiltration  processes;  the  walls  of  veins  are  infiltrated,  and  on 
reaching  the  lumen  the  cells  rapidly  multiply  until  a  mass  occludes 
the  vein  and  often  grows  for  a  considerable  distance  and  serves 
as  a  plug  which  prevents  hemorrhage  in  case  the  vein  is  cut,  but 
offers  an  unquestionable  guarantee  of  recurrence.  From  the  in- 
filtrating masses  in  the  veins  plugs  may  be  broken  off  by  accident 
or  in  the  natural  course  of  events,  and  produce  embolism  with  its 
symptoms,  or  metastases  by  lodging  in  vessels  which  are  not 
sufficiently  concerned  in  vital  processes  to  produce  symptoms. 
The  growth  of  processes  along  the  various  channels  of  the  body 
is  so  closely  allied  to  infiltration  proper  that  further  elaboration 
is  deemed  unnecessary.  The  growth  of  sarcomata  along  the 
coarser  channels  has  already  been  referred  to.  The  same  thing 
occurs  in  sarcoma  of  the  bone  or  periosteum;  once  it  passes  the 
limits  of  its  capsule  it  may  send  processes  along  the  Haversian 
canals  or  the  channels  conducting  the  blood-vessels  until  the 
periosteum  or  marrow  is  respectively  invaded.  So,  too,  in  sarcoma 
of  the  eye,  the  growth  may  invade  the  veins  and  extend  along 
them  until  it  reaches  the  surface  of  the  sclerotic,  where  it  produces 
small  nodules  in  the  venae  vorticosae. 

Mediastinal  lymphosarcomata  will  gradually  surround  nerves, 
bronchi,  vessels,  and  pericardium,  enter  the  lung  at  the  root,  fol- 
lowing the  structures  entering  there,  and  compress  and  collapse 
them  until  their  function  is  destroyed.  It  may  grow  upward 
under  fascial  planes,  underneath  the  cervical  muscles,  and  expand 
on  reaching  the  triangles  of  the  neck,  not  as  metastases,  but  as 
one  tumor  mass.  Likewise,  in  sarcomata  occurring  about  the 
spinal  column,  paraplegia  may  result  from  a  direct  growth  of  the 
tumor  through  the  intervertebral  foramina  and  intraspinal  en- 
largement occur,  which  produces  pressure  on  the  cord.  There 
is  no  nook  or  cranny  through  which  these  tumors,  hideous  alike 
to  the  surgeon  and  the  patient,  will  not  enter  so  easily,  so  quickly, 
and  with  so  little  trace  that  the  surgeon  must  not  only  overlook 
such  extension,  but  may  be  compelled,  even  though  suspecting  it, 
to  refrain  from  an  attempt  at  removal. 

From  the  preceding  discussion  of  infiltration  it  is  clear  that 
no  structure  of  the  body  is  immune  to  invasion  of  its  substance  by 
sarcoma,  and  while  the  tumor  may  be  movable  at  the  beginning, 
there  comes  an  indefinite  time,  the  more  malignant  the  tumor,  the 
earlier,  from  which  immobility  is  .established ;  and  that  as  the  in- 
filtration continues  it  may  bring  anatomic  structures  normally 
movable  in  relation  to  each  other  into  an  inseparable  and  often 
indistinguishable  mass. 


SARCOMA  531 

Metastases. — There  can  be  no  doubt  that  tumor-cells,  both 
benign  and  malignant,  gain  access  to  the  blood-stream,  and  pos- 
sibly to  the  lymphatics  occasionally,  benign  cells  more  rarely  but 
without  doubt,  as  indeed  may  happen  with  normal  tissue-cells, 
and  malignant  cells  very  frequently.  The  growth  of  such  cells 
into  tumor  masses,  essentially  of  the  same  nature  as  the  structure 
from  which  they  originated,  depends  on  the  power  of  the  cells  to 
take  hold  at  a  new  point  and  to  multiply  into  a  tumor  mass,  on 
the  resistance  shown  by  the  tissues  at  the  site  of  lodgment  and  the 
influence  trauma  and  disease  may  have  on  this  resistance.  Hence, 
we  are  in  position  to  understand  how  it  happens  that  with  marked 
uniformity  certain  organs  escape  metastases,  and  others  with  as 
great  uniformity  are  affected  by  them,  and  how  malignant  tumors 
of  certain  structures  show  a  predilection  to  metastasize  in  certain 
anatomic  structures,  as,  for  example,  the  preference  of  melanotic 
metastases  for  the  liver,  facts  which  cannot  be  explained  on  a 
theory  of  chance  distribution,  and  which  are  supported  by  our 
knowledge  of  the  distribution  of  metastatic  abscesses  in  pyemia. 

The  histologic  structure  and  the  method  of  cell  multiplication 
in  sarcomata  show  the  ease  with  which  the  cells  of  a  sarcoma  might 
get  into  the  circulating  blood;  the  blood-vessels  are  abundant, 
relatively  large,  with  no  vessel  wall  save  a  single  layer  of  intinui 
cell>  separating  them  from  the  tumor-cells,  and  in  many  instances 
even  no  intima  is  present,  the  blood  coursing  through  channels 
who-e  wall-  are  made  up  of  tumor-cells.  The  absence  of  connective 
ti>-ue  in  sarcomata  and  the  greatest  multiplication  of  cells  around 
the  I >lood- vessels  favors  the  same  course.  In  addition  to  this,  the 
infiltration  of  normal  vessels  by  sarcoma  cells  and  their  growth 
alonu;  the  lumen  may  similarly  serve  as  the  source  of  metastases. 
With  the  above  facts  clearly  before  the  reader,  he  cannot  fail  to 
appreciate  the  evil  influence  trauma  may  play  upon  a  sarcoma  by 
liberating  cells  from  the  tumor  into  the  circulation;  how  massage 
or  unnecessary  manipulation  are  not  only  superfluous,  but  hazard- 
on-:  how  it  becomes  a  dangerous  practice  to  cut  into  the  tumor 
mass  for  a  microscopic  section,  especially  unless  it  is  done  for  im- 
mediate use  and  the  wound  is  allowed  to  remain  open  meantime; 
how  in  operation  for  these  tumors  Esmarch's  bloodless  method  is 
contra-indicated;  how  gentle  handling  of  the  tumor  is  require  I. 
and  why  the  tumor  mass  should  never  be  lacerated  or  incised; 
for  if  by  any  of  these  procedures  sarcoma  cells  are  liberated  and 
gain  the  general  circulation  they  render  hopeless  a  case  that  might 
otherwix-  be  curable.  There  is  no  definite  time  prior  to  which  it 
can  be  said  that  meta>ta-is  has  occurred,  and  if  we  remember  that 
it  require-  -nine  time  for  the  meta.-ta>ixing  cells  to  gain  a  footing 
and  produce  a  discoverable  tumor,  and  the  fact  that  certain  very 


532  PRINCIPLES   OF   SURGERY 

malignant  tumors  metastasize  exceedingly  early,  we  may  under- 
stand how  impossible  it  is  ever  to  say  positively  that  no  metas- 
tasis has  occurred.  Metastases  occur  doubtless  with  far  greater 
frequency  after  an  encapsulated  tumor  destroys  its  capsule,  but 
the  possibility  of  metastasis  during  encapsulation  cannot  be 
doubted,  as  even  benign  tumors  occasionally  are  widely  distributed 
by  this  process. 

The  metastases  of  sarcoma  may  be  few  or  numerous  and  of 
varying  size.  Occasionally  the  first  evidence  the  patient  has  of 
a  malignant  tumor  is  the  appearance  of  secondary  tumors,  or  of 
some  accident  such  as  spontaneous  fracture  made  possible  by 
such  a  tumor.  The  cell  type  of  secondary  tumors  is,  of  course, 
identical  with  that  of  the  parent  growth. 

The  lodgment  of  malignant  tumor-cells  at  a  point  remote  from 
the  primary  growth  does  not  signify  necessarily  that  they  must 
begin  at  once  to  proliferate.  They  may  remain  dormant  for  a 
large  number  of  years  and  develop  into  a  tumor  of  the  same  type 
as  the  original,  with  no  evidence  of  recurrence  in  situ.  Hence,  the 
necessity  for  a  period  of  three  to  five  years  after  operation  before 
a  sarcoma  patient  can  be  reported  as  cured.  And  cases  of  recur- 
rence after  the  five-year  limit  are  seen  occasionally. 

It  has  been  too  universally  emphasized  that  sarcomata  do  not 
produce  glandular  enlargement  or  metastases.  As  a  rule,  they  do 
not,  but  exceptions  are  sufficiently  numerous  to  warrant  a  pretty 
constant  outlook  for  such  cases.  From  the  structural  standpoint 
small  round-celled  and  melanotic  sarcomata  invade  the  lymph- 
nodes  secondarily  more  frequently;  the  last-named  type  usually 
produces  lymph-node  involvement,  and  lymphosarcoma  habitually. 
While  a  rare  case  of  lymph-node  metastasis  may  be  seen  elsewhere, 
generally  speaking,  the  most  common  sites  in  which  sarcomata  are 
productive  of  such  lesions  are  the  tonsil,  the  testicle,  and  the  thy- 
roid gland.  In  these  structures  the  lymph-nodes  should  be  investi- 
gated as  thoroughly  as  in  cases  of  cancer. 

Sudden  Enlargement. — A  very  significant  phenomenon  occa- 
sionally observed  in  sarcomata  is  the  rapid  or  sudden  increase  in 
the  size  of  the  tumor,  an  increase  which  could  not  be  due  to  cell 
proliferation,  owing  to  the  suddenness  of  its  appearance.  It 
is  due  to  hemorrhage  into  the  tumor  mass,  and  this  hemorrhage 
occurs  spontaneously  or  as  the  consequence  of  an  injury.  It  is 
not  unusual  to  find  medium  or  small  hemorrhagic  spots  on  the  cut 
surfaces  of  sarcomata.  The  explanation  of  this  tendency  in  sar- 
coma is  easily  found  by  considering  for  a  moment  the  structure  of 
the  tumors  and  the  relation  of  the  blood-supply  to  the  tumor 
parenchyma. 

Pain. — I  have  already  discussed  pain  in  malignant  tumors 


SARCOMA  533 

g< -iit  -rally.  It  is  only  necessary  here  to  emphasize  those  statements 
in  their  especial  relation  to  sarcoma.  It  has  been  impressed  upon 
the  mind  of  the  laity  and  of  the  medical  profession  that  sarcomata 
an  essentially,  inherently  painful;  but  they  are  not,  and  it  may  be 
stated  emphatically  that  the  majority  of  them  never  produce 
pain  until  they  are  well  advanced,  except  as  the  result  of  pressure 
on  -cnsitive  structures,  or  by  virtue  of  some  complication  or  acci- 
dent, such  as  inflammation,  ulceration,  or  torsion.  Later  some 
pain  or,  rather,  discomfort  may  attend  them,  but  painful  sarco- 
mata of  the  soft  structures  are  rare.  On  the  other  hand,  sarco- 
mata arising  in  bone  may  be  excrutiatingly  painful  from  a  very 
early  period,  and  they  are  usually  passed  by  with  a  diagnosis  of 
rheumatism  and  a  prescription  of  salicylates  until  the  local  signs 
of  tumor  formation  force  themselves  upon  the  observer.  In  the 
acute  forms  of  sarcoma  the  general  and  local  behavior  may  be 
very  similar  to  that  of  inflammation. 

Cachexia. — Another  late  symptom  is  cachexia.  It  invariably 
appears  in  cases  allowed  to  take  their  course,  but  it  appears  late — 
i.  e.,  after  the  tumor  has  advanced  far  enough  to  make  severe 
inroads  on  the  patient's  vitality  or  after  the  advent  of  complica- 
tions. Hemorrhage,  ulceration,  and  infection  hasten  the  appear- 
ance of  this  symptom.  When  cachexia  plainly  shows  its  presence 
it  is  very  late  or  too  late  to  offer  much  hope.  The  majority  of 
sarcoma  cases  present  themselves  while  still  in  robust  health. 

Fever. — The  temperature  may  rise  and  run  an  irregular  course. 
This  symptom  is  seen  hi  sarcoma  of  the  viscera  with  sufficient 
frequency  to  render  it  of  slight  diagnostic  value.  It  occurs  also 
in  acute,  rapidly  growing  sarcomata,  and  at  times  in  sarcoma  of  the 
osseous  system.  The  temperature  usually,  when  elevated,  ranges 
from  100°  to  101°  F.,  sometimes  reaches  103°  F.,  and  rarely  104°  F. 

In  acute  sarcomata  there  will  often  be  observed  a  local  rise 
of  temperature  which  may  with  the  other  local  symptoms  cause 
confu-ion  in  differentiating  the  condition  from  an  acute  inflam- 
mation. 

Hilateral  Sarcomata. — Occasionally  two  sarcomata  are  seen  to 
ari-e  at  about  the  same  time  or  in  moderately  close  succession, 
but  apparently  independent  of  each  other.  This  is  observed  more 
frequently  in  certain  paired  organs,  namely,  testicles,  ovaries,  eyes, 
kidneys,  adrenals,  and  erura  eerebri.  This  renders  it  necessary  to 
examine  the  organ  of  the  opposite  side  with  especial  care  before 
rendering  an  opinion. 

Crinnri/  /•' hidings. — Occasionally  the  appearance  of  melanin 
in  the  urine  or  the  discovery  of  melanogen  during  urinalysis  serves 
as  the  fir>t  true  evidence  pointing  to  the  diagnosis  of  melanotic 
-arcoma.  However,  since  these  appear,  as  a  rule,  on  the  surface  of 


534  PRINCIPLES   OF   SURGERY 

the  body,  such  evidence  would  be  superfluous  except  in  concealed 
tumors. 

Diagnosis  of  Special  Forms  of  Sarcoma. — It  is  important  at 
tunes  not  only  to  know  that  a  sarcoma  is  present,  but  to  know 
to  which  type  it  belongs.  This  can  be  done  satisfactorily  in  many 
instances,  while  in  others  it  is  impossible.  We  must  content 
ourselves  usually  with  the  diagnosis  of  sarcoma  without  being 


Fig.  160. — Osteosarcoma  arising  from  spinal  column. 

able  clinically  to  say  what  type  of  cellular  structure  it  has.  Fibro- 
sarcoma  is  the  form  commonly  appearing  in  the  soft  structures 
and  often,  too,  arising  from  bone,  periosteum,  or  cartilage,  and 
can  be  recognized  by  the  symptoms  and  signs  already  given  for 
sarcoma  in  general. 

Chondro-  and  osteosarcoma,  by  which  is  meant  sarcomata 
containing  these  histologic  elements,  usually  arise  from  bone, 
cartilage,  or  periosteum,  although  they  occasionally  appear 


SARCOMA  535 

as  heterologous  tumors.  Their  recognition  depends  upon  the 
presence  of  factors  which  indicate  their  malignant  nature  plus  the 
evidence  of  the  presence  of  bone  or  cartilage.  The  osseous  and 
cartilaginous  elements  are  often  so  outnumbered  by  the  cellular 
elements  that  no  clinical  evidence  of  the  presence  of  the  former  can 
be  had.  A  skiagraph  will  frequently  be  of  service  in  recognizing 
the  presence  of  these  denser  structures. 

They  appear  usually  in  the  long  bones  and,  by  preference,  at 
their  extremities,  hi  the  scapula  and  clavicle,  in  the  ossa  innomi- 
nata,  the  sternum,  and  the  skull. 

Myxosarcomata  are  more  likely  to  be  confused  with  suppurative 
and  tubercular  lesions  and  with  cysts  than  any  other  form  of  sar- 
coma, owing  to  their  consistency.  When  they  grow  larger  and 
infiltrate  the  surrounding  structures  their  recognition  is  easier. 
They  are  found  quite  frequently  in  the  very  young  (sometimes 
from  the  umbilicus)  and  are  sometimes  congenital.  Their  dis- 
tribution in  the  body  is  extensive,  although  they  arise  more  fre- 
quently from  the  skin,  subcutaneous  tissue,  and  the  fibrous  tissue 
forming  the  septa  and  fascise.  They  often  arise  from  the  nerves 
where  they  may  be  multiple,  or  from  the  meninges,  and  from  peri- 
osteum and  marrow. 

They  arise  by  preference  from  the  arm,  buttock,  and  thigh,  and 
are  e-pceially  frequent  in  the  lower  end  of  the  femur,  just  above 
t  lie  knee.  The  testicles,  ovaries,  lungs,  liver,  and  kidneys  may  give 
origin  to  them,  other  organs  less  frequently.  Their  nature  may  be 
-ometimes  recognized  by  aspiration,  but  the  practice  is  not  war- 
ranted. 

Lymphosarcomata  are  recognized  by  their  location  and  the 
manner  of  growth.  They  arise  from  pre-existing  lymphatic  tissue, 
usually  in  the  regions  abundantly  supplied  with  lymph-nodes. 
They  are.  therefore,  more  frequently  found  in  the  neck,  axilla, 
mediastinum,  and  abdomen.  They  may  originate  in  the  thymus, 
the  tonsils,  from  the  lymphoid  tissue  of  the  alimentary  tract,  and, 
rarely,  from  the  marrow  of  bones.  They  appear  with  the  ordinary 
characteristics  of  fibrosarcoma,  but  after  the  surrounding  lymph- 
nodes  are  invaded  and  prior  to  the  coalescence  of  the  group  into  an 
indi-tinimi>hable  mass  they  can  be  recognized  by  palpation. 
i:\en  then  the  infiltration  of  surrounding  structures  will  scarcely 
leave  a  question  of  its  sarcomatous  nature.  The  tumors  tend  to 
ulcerate  when  situated  near  the  surface.  The  condition  may  be 
confused  with  pseudoleukemia  prior  to  infiltration  of  the  peri- 
nodular  ti->ue-:  :i  Mood  examination,  however,  will  clear  the  diag- 
no-i>  unmistakably:  besides,  the  cour.-e<  of  the  two  diseases  are  so 
different  as  to  render  them  easily  distinguishable  in  most  in- 
stances. 


536  PRINCIPLES   OF   SURGERY 

In  connection  with  lymphosarcoma  it  is  necessary  to  mention 
myeloma,  which  appears  in  two  forms,  the  first  passing  under  the 
name  of  giant-celled  myeloma,  and  the  second  under  the  name 
of  myeloma  multiplex,  or  myelomatosis,  and  chloroma.  The 
classification  of  these  conditions  with  sarcomata  is  seriously 
questioned  by  many  pathologists,  and  their  general  behavior  as 
well  as  their  structure  unquestionably  warrants  such  doubt. 
Inasmuch  as  they  affect  the  osseous  system  altogether,  they  will 
be  more  fully  discussed  under  Sarcoma  of  Bone. 

Pigmented  Sarcomata. — Since  they  occur  usually  on  the  cu- 
taneous surfaces,  hi  the  eye,  and  occasionally  on  the  mucous  mem- 
branes of  the  apertures  of  the  body,  these  tumors  are  easily  recog- 
nized by  their  color,  and,  in  addition,  the  usual  characteristics  of 
sarcomata,  of  which  they  represent  the  most  malignant  form. 
They  frequently  originate  from  pigmented  moles  and  nevi.  It 
must  not  be  inferred  from  this,  however,  that  they  arise  solely 
from  pre-existing  lesions.  When  originating  de  novo  they  appear  as 
discolored  bluish  or  brownish  growths  whose  color  is  manifest 
through  the  overlying  whitish  cuticle.  Their  color  may  be  uni- 
form or  mottled  and  may  vary  from  a  brown  to  a  jet  black.  They 
usually  protrude  abruptly  from  the  surface,  when  they  begin  to 
grow  rapidly  and  are  often  pedunculated.  They  are  prone  to 
ulcerate  and  bleed,  and,  of  course,  are  then  subject  to  infection 
and  emit  odors  of  decomposition.  The  discharge  from  their 
surface  often  stains  the  dressings  with  the  contained  pigment. 
Glandular  involvement  takes  place  early  once  the  tumor  reaches 
a  stage  of  rapid  growth,  which  often  occurs  after  the  capsule  is 
ruptured  by  growth,  by  accident,  or  meddlesome  or  imperfect 
treatment,  such  as  ligation  of  the  pedicle  of  a  mole  or  incomplete 
destruction  or  removal  by  cautery  or  knife.  It  should  be  empha- 
sized again  that  incomplete  surgery  on  pigmented  growths  is,  of 
all,  the  most  unpardonable.  Soon  after  the  tumor  begins  a  rapid 
growth  numerous  nodules  appear  in  the  tegument  surrounding  it, 
and  remote  metastases  are  early  and  rapidly  produced.  Usually 
the  metastases  are  pigmented  just  as  the  primary  growth,  but 
non-pigmented  growths  may  form  a  certain  percentage  of  the 
secondary  tumors.  The  blood  may  show  evidence  of  the  pigment 
(melanemia),  the  urine  may  be  discolored  with  melanin  or  contain 
melanogen,  and  in  rare  instances  the  tissues  of  the  body  generally 
may  be  discolored.  Melanotic  sarcomata  occur  at  any  age,  and 
may  appear  on  any  part  of  the  body  surface,  though  with  greater 
frequency  in  the  regions  most  abundant  in  pigmented  growths 
and  in  the  eye,  and  are  especially  likely  to  arise  on  the  face  and  the 
upper  and  lower  extremities. 

Microscopic  Diagnosis. — No  tumor  should  be  treated  by  the 


SARCOMA  537 

radical  measures  required  in  cases  of  malignancy  until  it  has  been 
definitely  and  unquestionably  settled  that  it  is  malignant,  and, 
if  possible,  what  the  degree  of  malignancy  is.  On  the  other  hand, 
no  tumor  that  bears  any  suspicious  marks,  whether  they  be  due  to 
its  position  or  its  behavior,  should  be  allowed  to  continue  untouched 
until  it  manifests  its  true  nature  in  a  clinical  way.  This  can  be 
done  only  with  a  microscope  and  by  a  competent  pathologist,  for 
it  i-  often  extremely  difficult  to  differentiate  sarcomatous  tissue 
from  other  lesions,  and  sometimes  impossible  unless  the  gross 
specimen  or  the  clinical  behavior  be  taken  into  consideration. 
T\v.  >  plans  are  employed  for  this  purpose,  each  applicable  in  certain 
instances.  It  is  preferable  to  prepare  the  patient  for  operation, 
remove  the  tumor  in  toto,  if  possible,  and  turn  it  over  to  the  micro- 
scopist  for  immediate  examination  by  the  frozen  method.  Ten 
to  fifteen  minutes  will  be  required  for  a  report,  during  which  time 
the  patient  is  lightly  held  under  anesthesia.  If  the  report  is  posi- 
tive, radical  work  may  proceed;  if  negative,  the  wound  is  closed 
and  the  negative  findings  should  be  confirmed  by  the  slower  and 
more  accurate  processes  of  hardening.  If  the  tumor  cannot  be 
removed,  it  is  necessary  to  remove  a  section  for  examination. 
This  section  should  come  from  the  newer,  rapidly  growing  portion 
of  the  tumor,  and  if  possible  the  circulation  should  be  shut  off 
from  the  region  by  a  tourniquet  or  otherwise,  for  there  can  be  no 
doubt  that  cells  may  be  liberated  by  this  procedure  which  develop 
into  remote  metastases  long  after  a  satisfactory  operation  has  been 
done.  The  same  danger  is  to  be  remembered  in  connection  with 
a-piration  of  the  tumors  in  the  hope  of  recovering  diagnostic 
material.  The  second  plan  is  the  so-called  slow  method,  which  is 
unquestionably  more  satisfactory  in  many  ways.  However,  the 
tumor  should,  when  it  is  feasible,  be  removed  as  a  whole  or  should 
include  with  it  more  or  less  of  the  surrounding  tissues.  The  slow 
method  is  especially  objectionable  when  only  a  part  of  the  tumor 
is  excised,  since  the  blood-supply  cannot  be  permanently  shut  off 
and  meta-tasos  have  all  the  better  chance  to  occur. 

Sarcoma  of  Special  Structures  and  Organs. — Alimentary 
Tract. — The  stomach  is  rarely  affected  by  sarcoma,  primary  or 
M-i'..ndary.  When  primary  sarcomata  appear  they  usually  come 
in  the  muscularis,  submucosa,  rarely  from  the  mucous  membrane, 
and  therefore  may  appear  as  intramural,  internal  or  external. 
The  latter  is  oeca>ion:illy  pedunculated;  otherwise  they  are  usually 
non-pedunculated  tumors.  Those  found  in  the  muscle  are  usually 
round-celled,  those  arising  from  the  mucosa  and  submucosa  are 
round-celled  or  lymphosarcomata :  the  latter  often  lining  practi- 
cally the  whole  of  the  stomach  with  tumor  nodules;  those  formed 
from  the  sulmmcosa  are  round-  or  spindle-celled  or  myxosarco- 


538  PRINCIPLES   OF   SURGERY 

mata.  Sarcoma  of  the  stomach  is  found  more  frequently  between 
the  ages  of  forty  and  fifty,  although  no  age  is  exempt,  and  lympho- 
sarcomata  are  especially  favored  in  the  earlier  years  of  childhood. 
The  intramural  round-celled  tumors  may  grow  rapidly,  become 
cystic,  rupture  into  the  cavity  of  the  stomach,  and  suppurate 
abundantly.  Occasionally  fibromyoma  of  the  stomach  becomes 
sarcomatous.  Usually  sarcomata  of  this  organ  are  of  average 
consistency,  although  they  are  sometimes  supplied  with  abundant 
fibrous  tissue  (fibrosarcoma)  and  may  be  very  hard.  They  can 
usually  be  distinguished  fairly  well  macroscopically  or  micro- 


Fig.  161. — Multiple  myxosarcoma  of  intestine.  In  X  there  is  intussus- 
ception due  to  large  mass — about  the  size  of  a  baseball.  First  symptom  was 
"locked  bowels"  seven  days  before  death.  At  O  is  a  mass  cut  open.  At  B  is  a 
smaller  tumor. 

scopicaliy  from  carcinoma,  but  round-celled  tumors  of  the  inner 
layers  when  they  infiltrate  the  walls  extensively  put  both  the 
pathologist  and  the  microscopist  to  a  severe  test  to  differentiate 
them  from  carcinoma.  Sarcomata  of  the  stomach  rarely  result 
in  stenosis  and  are  less  disposed  to  ulcerate  than  carcinomata,  and, 
as  a  rule,  do  not  so  rapidly  produce  death. 

Secondary  sarcomata  of  the  stomach  are  usually  multiple,  mela- 
notic  tumors,  or  non-pigmented,  round-celled  tumors ;  rarely  they 
are  spindle-celled.  The  secondary  tumors  are  usually  nummular 
and  situated  in  the  mucosa  or  submucosa,  with  their  surfaces 
often  more  or  less  cupped. 


SARCOMA 


539 


Sarcomata  are  rare  in  the  intestines.  They  occur  three  times 
as  frequently  in  males  as  in  females.  They  are  more  often  found 
in  the  terminal  extremity  of  the  small  intestine  and  in  the  cecum, 
very  rarely  in  the  appendix.  The  types  chiefly  found  are  round- 
celled  (occasionally  alveolar),  less 
frequently  spindle-celled,  and  mel- 
anosurcoma,  the  latter  appearing 
only  in  the  rectum.  Lymphosar- 
comata  occur  in  both  the  small 
and  large  intestine,  preferring 
the  former.  Primary  sarcoma  of 
tin'  inte-tines  is  usually  a  single 
tumor,  very  exceptionally  mul- 
tiple; lymphosarcoma  is  more 


Fin.  Ki'J.     Myxosarroma  of  bone. 


l'"\K.  163. — Same  as  FIR.  162,  six 
months  after  resection  and  trans- 
plantation of  portion  of  other  tibia. 


frequently  multiple  than  the  other  types.  Sarcoma  may  arise 
from  murnsa,  suhinucosa,  or  muscularis,  grows  as  a  stenosing 
ma--,  involving  the  whole  circumference  of  the  gut,  or  sometimes 
affecting  only  a  portion  of  the  circumference,  when  it  may  be 
pedunculated  an<l  Kehave  as  a  polyp.  They  may  be  the  cause  of 


540  PRINCIPLES   OF   SURGERY 

intussusception  before  reaching  a  large  size.  They  are  found  in 
all  ages  and  may  reach  an  enormous  size,  especially  when  arising 
from  the  large  intestine.  They  are  prone  to  ulcerate  and  become 
necrotic  or  degenerate.  They  can  often  be  distinguished  from 
carcinoma  only  by  microscopic  examination.  Lymphosarcomata 
infiltrate  the  wall  more  extensively  and  may  involve  a  consider- 
able length  of  the  gut.  This  type  often  invades  the  peritoneum  and 
is  very  apt  to  produce  numerous  remote  metastases  at  an  early 
stage. 

Metastatic  sarcomata  of  the  intestines  occur  somewhat  more 
frequently  than  primary.  They  are  found  in  the  muscularis, 
submucosa,  in  the  peritoneal  covering,  the  appendices  epiploicse, 
and  at  the  mesenteric  attachment.  They  are  more  often  melanotic, 
seldom  disposed  to  ulcerate,  and  occasionally  produce  obstruction 
by  bulging  into  the  lumen  of  the  gut.  When  ulceration  occurs, 
and  the  tumor  infiltrates  and  more  or  less  completely  encircles 
the  gut,  they  resemble  carcinoma  very  closely. 

Bone  and  Periosteum. — I  have  said  already  that  primary  sarco- 
mata of  bone  and  periosteum  may  be  either  osteosarcoma  or 
chondrosarcoma,  or,  on  the  other  hand,  be  of  any  of  the  soft 
varieties  except  melanosarcoma.  Hence,  it  must  be  emphasized 
here  that  many  sarcomata  arising  from  bone,  periosteum,  and 
cartilage  are  not  possessed  of  the  power  to  form  bone  or  cartilage 
as  the  tumors  grow,  but  are  at  their  beginning  and  remain  soft 
and  flesh-like  in  their  consistency,  as  those  arising  from  fibrous 
tissue  rests  in  the  soft  parts,  which  are  hence  called  fibrosarcomata. 

Periosteal  sarcomata  appear  by  predilection  near  the  ends  of 
the  long  bones,  especially  the  lower  end  of  the  femur  and  the  upper 
end  of  the  tibia  and  humerus,  but  are  by  no  means  confined  to  these 
sites.  They  are  usually  round-  or  spindle-celled  tumors,  but  may 
be  mixed  celled  or  giant  celled.  They  are  usually  firm  tumors, 
but  may  be  extremely  soft;  they  occasionally  assume  the  form  of 
chondrosarcoma  or  of  ossifying  sarcoma  (osteosaroma) .  The 
growth  may  assume  more  or  less  a  spindle  shape  and  gradually 
surround  the  bone.  The  bone  beneath  a  periosteal  sarcoma  is 
sometimes  so  completely  destroyed  by  the  growth  of  the  tumor 
and  its  infiltration  of  the  bone  that  a  spontaneous  fracture  results. 
On  the  other  hand,  there  may  develop  an  ossifying  osteomyelitis, 
which  adds  to  the  density  of  the  bone  until  it  acquires  the  hard- 
ness and  solidity  of  ivory;  as  periosteal  sarcomata  increase  in  size 
they  may  infiltrate  the  surrounding  periosteal  covering  and  invade 
the  surrounding  soft  structures  just  as  sarcoma  of  the  soft  tissues. 
The  metastases  from  periosteal  sarcomata,  more  common  by  far 
in  the  lungs,  may  be  of  the  ossifying  type  or  soft,  and  show  only 
partial  calcification  of  their  substance. 


SARCOMA 


541 


A  very  common  form  of  periosteal  sarcoma  is  seen  in  the  form 
of  epulis  which  arises  from  the  periosteum  covering  the  alveoli, 
usually  of  the  lower  jaw,  and  runs  a  rather  benign  course  as  a  rule. 
It  may  be  a  pedunculated  or  sessile  tumor  and  frequently  originates 
between  two  teeth.  It  is  made  up  of  spindle  cells  with  a  varying 


I  in  1T>4.— Skiauraph  <>f  \>-\i  ten  months  after  transplantation  of  Kraft 
from  ophite  tU.ia.  The  U|)IHT  end  of  graft  failed  to  unite  and  required  the 

employment  of  a  lime's  plate. 

admixture  of  giant  cells.    Occasionally  it  contains  bone,  although 
it  does  not  become  completely  o-sified. 

In  prrio-tral  >arcoma  meta>ta>es  are  likely  to  occur  rela- 
tively very  early,  and  the  tumors  are,  as  a  rule,  very  rapid  in 
growth.  There  is  danger  of  confusing  the  diajriuM-.  with  syphilitic 
lesions  and  especially  with  tuberculous,  which  cannot  always  be 


542 


PRINCIPLES   OF   SURGERY 


cleared  up  by  the  Wassermann  reaction  and  the  tuberculin  testsr 
for  it  must  be  remembered  that  a  syphilitic  or  tuberculous  indi- 
vidual may  develop  sarcoma.  The  differentiation  is  all  the  more 
difficult  if  the  lesion  is  near  an  articulation.  The  acute  and 
rapidly  growing  sarcomata  may  be  confused,  too,  with  inflamma- 
tory processes,  and  occasionally  are  associated  with  a  continued 
fever.  The  continuous  growth,  the  outlines  of  the  tumor,  the 


Fig.  165. — Skiagraph  of  myxosarcoma  of  humerus  in  a  boy  sixteen  years  old, 

nodular  surface,  if  present,  the  continuation  of  growth  whether 
the  part  is  functionating  or  at  rest — while  inflammatory  processes, 
particularly  the  chronic  types,  are  improved  by  this  treatment — 
favor  the  diagnosis  of  sarcoma.  Spontaneous  fracture  and  occa- 
sionally spontaneous  dislocation  are  evidence  of  malignancy,  al- 
though they  are  not  to  be  accepted  as  pathognomonic.  The 
employment  of  a  skiagraph  is  often  of  the  greatest  value  in  differ- 


SARCOMA 


543 


entiatinj:  sarcoma  from  other  lesions.  Myositis  ossificans  is  extra- 
peritoneal  and  can  usually  be  distinguished  if  a  skiagraph  be 
studied  in  conjunction  with  the  symptoms  and  history.  Perios- 
tea 1  sarcoma  occurs  with  much  greater  frequency  in  the  young. 

Sarcoma  arising  from  bone  is  known  as  myelogenous  sarcoma. 
They  are  made  up  of  cells  of  the  most  varied  types,  chief  of  which 
arc  small  round-celled  sarcoma,  large  round-celled  sarcoma, 
spindle-celled  sarcoma,  often  with  a  marked  variation  in  the  size 
of  the  cells  in  a  given  tumor  or  with  considerable  abundance  of 
fibrous  tissue,  and  there  often  appear  large  numbers  of  enormous 


166. — Photograph  of  excised  bone.     San 


wn  in  Fig.  165. 


giant  cells  admixed  with  the  spindle  or  connective-tissue  cells, 
the  uio-t  perfect  examples  of  giant-celled  sarcoma.  Sometimes 
the  cell-  are  alveolar,  as  also  the  periosteal  tumors  may  be.  There 
frequently  appear  large  numbers  of  blood-vessels  in  the  substance 
of  myelogenous  sarcomata,  telangiectatic  or  hemangiosarcomata, 
which  may  pulsate  and  cause  confu-ion  with  bone  aneurysms;  fre- 
quently, too,  they  produce  a  bruit  not  unlike  that  so  characteristic 
of  aneurysni.  The  -ites  of  predilection  are,  above  all.  the  lower 
jaw,  then  the  upper  jaw,  the  epiphyses  of  the  long  bones,  espe- 
cially the  tibia  and  the  bones  of  the  forearm.  Occasionally  the 


544  PRINCIPLES   OF   SURGERY 

diaphyses  are  affected.  Many  epulides  are  of  the  myelogenous, 
rather  than  the  periosteal,  type. 

Myelogenous  sarcomata  may  gradually  enlarge  and,  while 
destruction  of  the  original  normal  bone  takes  place,  form  a  shell 
of  bone  over  their  surface  which  may  be  so  thin  as  to  crackle  under 
moderate  pressure,  the  so-called  parchment  crackling.  Cyst  for- 
mation is  not  uncommon,  and  many  of  the  bone-cysts  reported 
are  due  to  this  origin,  as  has  been  revealed  by  finding  the  char- 
acteristic sarcoma  structure  in  the  thin  cyst  walls.  Retrograde 
changes  are  common  and  hemorrhage  into  the  tumor  substance 
frequent.  The  tumors  are  sometimes  myxomatous.  Bone  forms 
often  in  the  substance  of  the  tumor  and  often  assumes  the  form  of  a 
large  number  of  spicules  (needles)  radiating  through  the  tumor 
mass,  or,  in  cystic  sarcomata,  they  form  osseous  septa  separating 
the  various  pockets  of  the  multilocular  growth  from  each  other. 
Spontaneous  fracture  is  occasionally  a  symptom,  and  is  more  likely 
to  occur  in  the  soft  non-ossifying  myelogenous  sarcomata.  Osteo- 
sarcomata  are  very  rarely  congenital. 

Pain  may  be  the  first  evidence  that  the  host  of  a  bone  sarcoma 
is  diseased,  and  usually  is  interpreted  as  rheumatism  or  neuralgia, 
although  no  other  symptoms  of  these  conditions  are  present,  and 
although  the  simple  resort  to  skiagraphy  would  lend  the  most 
valuable  evidence. 

Myelogenous  sarcomata  are  to  be  accepted  as  among  the  most 
benign,  taken  as  a  group;  this  is  especially  true  of  the  giant-celled 
tumors  or  myelomata.  Unlike  the  periosteal  type,  they  are  little 
disposed  to  infiltrate  the  surrounding  tissue,  although  they  may  do 
so ;  and  are  very  prone  to  produce  no  metastases,  which  when  they  do 
occur  are  more  abundant  in  the  lungs.  They  often  grow  directly 
into  the  veins  of  an  extremity  and  then  indefinitely  along  their 
lumina,  a  frequent  cause  of  recurrence  after  amputation.  Hence, 
in  every  instance  of  the  kind  the  veins  should  be  investigated 
thoroughly  before  an  opinion  is  ventured  concerning  the  prognosis. 
The  myelogenous  epulides  may  be  said  to  be  entirely  free  from  a 
tendency  to  produce  metastases,  although  they  are  likely  to  return 
in  situ  after  removal.  It  is  true  in  myelogenous  sarcoma,  however, 
as  it  is  in  general,  that  the  malignancy  of  the  tumor,  its  power  of 
infiltration,  its  disposition  to  metastasis  is  largely  determined  by 
the  size  of  its  constituent  cells,  the  smaller  cells  being  much  more 
dangerous.  Hence,  surgeons  have  come  to  recognize  in  their  prac- 
tice the  relative  innocence  of  those  myelogenous  tumors  whose 
cells  are  large  and  which  show  a  great  proportion  of  giant  cells, 
and  are  modifying  their  methods  of  treatment  accordingly  along 
much  more  conservative  lines. 

Occasionally  primary  multiple  myelogenous  tumors  occur  hi 


SARCOMA  545 

the  bones,  especially  in  the  femur,  the  ribs,  the  sternum,  the  ver- 
tebral column,  and  the  skull.  These  may  be  either  lymphosarco- 
mata,  which  are  truly  malignant  growths  capable  of  metastasis, 
or  the  genuine  myelomata,  which  arise  only  in  the  red  marrow 
an«  1  produce  no  metastasis.  These  primary  multiple  bone  tumors 
may  cause  extensive  destruction  of  bone.  The  presence  of  these 
tumors  is  indicated  by  the  appearance  in  the  urine  of  Bence-Jones 
bodies,  a  reaction  which  is  found  also  hi  cases  of  lymphatic  leu- 
kemia. 

Secondary  sarcomata  of  the  skeleton  are  chiefly  melanotic 
sarcomata,  derived,  as  previously  stated,  from  primary  tumors 
situate*!  usually  in  the  skin.  Rarely  an  osteosarcoma  produces 
practically  all  its  metastases  in  the  skeleton. 

Brain,  Cord,  and  Meninges. — These  structures  are  rarely  the 
site  of  primary  sarcoma,  and  the  tumors  cannot  be  differentiated 
from  other  lesions  which  similarly  produce  pressure  on  the  central 
organs  of  the  nervous  system.  The  bony  encasements,  the  perios- 
teum, and  the  meninges  are  affected  by  sarcoma  much  more  fre- 
quently than  the  brain  and  cord,  which,  however,  may  give  origin 
to  - 1 >in< lie-celled  or  mixed-celled  tumors  and  to  angiosarcoma. 
They  arise  from  the  connective  tissue  of  the  blood-vessel  supply. 
Sarcomata  cannot  ordinarily  be  distinguished  macroscopically 
from  gliomata  unless  metastases  have  occurred  in  the  brain  or 
remotely,  or  unless  the  tumor  has  shown  evidences  of  infiltration. 

Kidneys. — Sarcomata  of  the  kidneys  occur  with  considerable 
frequency  in  the  very  young  and  are  sometimes  congenital.  They 
are  capable  of  attaining  an  enormous  size,  records  of  tumors 
weighing  25  to  30  pounds  having  been  made.  These  large  tumors 
ut  in  the  child  an  appearance  of  the  abdomen  very  similar  to 
that  produced  by  enormous  cysts  in  adult  women.  They  are  very 
apt  to  be  bilateral,  so  that  one  can  offer  little  assurance  aside  from 
the  mortality  from  the  operation.  The  tumors  are  usually  very 
soft  and  vascular.  These  tumors  of  the  newborn  contain  glandular 
elements  and  may  show  striated  muscle-fibers.  They  have  thus 
been  spoken  of  as  adenosarcomata  or  adenomyosarcomata.  The 

amata  which  are  found  in  children  also  often  contain  adeno- 
itous  elements. 

Sarcomata  of  the  kidney  in  the  adult  are  less  frequent  and  not 
so  apt  to  be  bilateral.  They  are  either  round  or  spindle  celled, 
the  former  soft,  the  latter  more  firm.  It  is  often  necessary  to  dis- 
tinguish sarcoma  of  the  kidney  in  the  adult  from  carcinoma,  and 
this  can  be  done  clinically  only  when  the  disease  has  declared  itself 
positively.  Sarcomata  grow  to  a  larger  sixe  than  carcinomata. 
Pain  is  present  in  both,  and  hematuria  i>  present  in  a  largo  per- 
centage of  cases,  manifesting  itself  as  soon  as  the  pelvis  is  invaded. 
35 


546  PRINCIPLES   OF   SURGERY 

Hypemephroma  is  a  term  employed  to  cover  several  forms  of 
tumor  originating  in  the  kidney  from  presumably  misplaced  rests 
of  adrenal  (hypernephric)  tissue.  The  term  embraces  a  benign 
and  malignant  type.  The  exact  position  of  these  growths  La  the 
classification  of  tumors  is  much  disputed.  The  benign  form  is 
usually  given  as  a  type  of  adenoma.  The  malignant  type,  which 
especially  concerns  us  here,  is  classed  as  alveolar  or  angiosarcoma, 
as  perithelioma,  and  recently,  by  Stoerck,  as  carcinoma.  Their 
true  nature  cannot  then  be  asserted,  although  the  majority  have 


Fig.  167. — Hypemephroma.    Tumor  growing  into  pelvis  of  kidney.     Observe 
capsule  of  the  tumor. 

doubtless  considered  them  sarcomatous.  They  are  found  more 
frequently  hi  the  sixth  decade  of  life.  They  grow  more  slowly,  as 
a  rule,  than  either  carcinoma  or  sarcoma.  The  tumor  when  large 
often  appears  nodulated.  Pain  develops  in  most  cases  as  the  tumor 
enlarges;  it  is  not  a  constant  symptom.  Hematuria  is  often  the 
first  and  may  be  accepted  as  the  most  distinctive  symptom. 

Whether  sarcoma  or  hypernephroma  be  the  tumor  in  question, 
there  are  certain  pathologic  and  clinical  facts  to  be  noted.  The 
tumor  may  originate  within  the  kidney  substance  and  grow  to  a 


SARCOMA 


547 


considerable  size,  stretching  the  kidney  and  thinning  it  out  until 
it  may  give  a  false  impression  that  the  tumor  is  encapsulated. 
As  the  tumor  grows  it  may  and,  as  a  matter  of  fact,  usually  does 
break  into  the  pelvis  of  the  organ,  whence  the  symptom  hematuria, 
which  though  rare  in  children,  is  very  frequent  hi  adults,  and  serves 
as  the  first  evidence  in  more  than  half  the  cases;  the  ureter  may 
be  blocked  or  fragments  of  the  tumor  may  serve  as  the  origin  of 
stones.  The  thin  wall  of  the  kidney  and  its  capsule  may  rupture 
ami  allow  local  invasion  of  the  surrounding  structures,  even  the 
abdominal  viscera.  The  veins  are  very  frequently  invaded  by 
processes  of  the  tumor  growing  along  their  lumina  and  blocking 


Fin   UN  —  HVJM  rncphroma,  alveolar  type.     (Mjcrophotograph;  X  about  100.) 

them,  reaching  sometimes  even  into  the  vena  caya.  Metastases 
are  not  frequent  and  occur  most  frequently  in  the  lungs.  Hyper- 
nephromata  are  more  likely  to  produce  metastases  in  the  bones, 
and  occasionally  produce  enlargement  of  the  surrounding  lymph- 
nodes. 

Secondary  sarcomata  of  the  kidneys  occur,  although  they  can 
be  of  little  iinjwrtance  from  a  clinical  standpoint,  owing  to  the 
deep  situation  of  the  organs. 

Liver. — This  organ  is  rarely  the  site  of  primary  sarcoma.  The 
tumors  found  may  be  round,  spindle,  or  giant  celled.  The  latter 
appear  as  angio>arcoma.  Rarely  primary  pigmented  sarcoma 


548 


PRINCIPLES   OF   SURGERY 


of  the  liver  has  been  reported.  The  tumors  appear  as  single 
roundish  masses  or  as  several  nodules,  multiple  primary  sarcoma. 
The  single  primary  tumor  usually  arises  from  the  right  lobe,  and 
when  appearing  from  its  lower  surface  may  be  pedunculated. 
The  nodules  may  be  so  closely  opposed  as  to  become  confluent 
as  they  grow  larger.  Infiltration  may  occur  early  and  the  whole 
liver  gradually  become  invaded  by  the  tumor.  The  tumors 
appear  usually  in  adults,  but  may  be  seen  in  early  life.  Sometimes 
the  condition  is  secondary  to  cirrhosis.  Sarcoma  of  the  liver  is 
frequently  alveolar. 


Fig.  169. — Hypernephroma,  alveolar  type.    (Microphotograph;  X  about  250.) 
Same  as  Fig.  156. 

Metastatic  sarcoma  of  the  liver  is  much  more  common  than 
primary  growths,  and  these,  of  course,  belong  structurally  to  the 
type  of  the  primary  growth.  They  are  melanosarcomata  in  a 
large  percentage  of  cases,  and  may  be  the  first  cause  of  complaint, 
since  the  primary  growth  is  often  small  and  considered  by  the 
patient  as  being  of  no  consequence.  The  secondary  metastases 
from  a  melanotic  sarcoma  may  have  the  same  color  as  the  primary 
growth,  or  show  no  pigmentation  whatever.  Metastatic  liver 
sarcomata  are  usually  multiple  and  may  be  very  numerous, 
bulging,  as  a  rule,  from  its  surface,  and  rarely  are  umbilicated 
or  become  cystic.  Enormous  enlargement  of  the  liver  may  be 
produced.  Solitary  tumors  of  the  liver  may  reach  an  excessive 


SARCOMA 


549 


size  (that  of  an  adult's  head)  and  be  mistaken  for  the  primary 
growth,  unless  a  most  exhaustive  examination  be  given.  Usually 
met  astatic  sarcomata  of  the  liver  grow  as  isolated  masses  easily 
distinguishable  from  the  surrounding  tissues,  but  they  occasionally 
infiltrate  the  surrounding  zones,  sometimes  appearing  hi  a  radicular 
form,  owing  to  their  manner  of  spreading  in  the  vessels. 

Lungs. — Primary  sarcoma  of  the  lungs  is  exceedingly  rare,  but 
may  attain  an  enormous  size  and  infiltrate  the  entire  organ.  It 
can  rarely  be  diagnosed  by  microscopic  examination  of  the  sputum. 

Secondary  sarcoma  of  the  lungs,  on  the  contrary,  is  exceedingly 
common,  especially  when  the  primary  growth  is  situated  hi  certain 
organs.  (See  Sarcoma  of  the  Kidneys,  Periosteum,  etc.) 

Omentum. — Sarcoma  of  the  omentum  is  rare.  It  may  occur  as 
a  single  large  mass,  or  the  whole  omentum  may  be  studded  with 


Fig.  170. — Sarcoma  of  great  omentum. 

nodules  and  "resemble  a  cherry  pie."    They  are  fibro-  or  myxo- 
sarcomata  and  arc  spindle  celled  in  more  than  half  the  cases. 

vies-  The-e  organs  are  rarely  affected  by  sarcoma.  The 
tumors  are  usually  spindle  celled,  but  round-,  giant-,  and  mixed- 
idled  tumors  are  occasionally  observed.  Myxosarcomata  may  be 
found,  and  this  organ  is  one  of  the  rare  sites  serving  very  excep- 
tionally a>  the  site  of  a  primary  melanosarcoma.  Sarcocarcinoma, 
cystadenosarcoma,  and  adenosarcoma  are  sometimes  oh-erved. 
The  tumors  occur  in  young  women  especially,  but  are  relatively 
quite  frequent  in  children  and  rare  in  the  fetus;  in  either  instance 
they  may  he  bilateral. 

They  are  likely  to  be  of  the  alveolar  type  in  the  very  young  and 
thu>  come  to  re-emhle  cancer  microscopically.  The  tumors  are 
u>ually  firm,  nodulated  or  >inooth,  oval  or  oblong:  but  may  be 
soft,  rapidly  growing  (round  celled),  and  very  malignant.  Cystic 


550  PRINCIPLES   OF   SURGERY 

degeneration  is  frequent.  Sarcoma  of  the  ovaries  is  most  common 
in  children,  rare  between  the  sixteenth  and  twentieth  years, 
more  frequent  again  between  the  ages  of  twenty  and  thirty,  less 
frequent  then  till  the  menopause,  and  after  this  again  more  fre- 
quent. They  are  usually  unilateral  after  the  twentieth  year 
(Bland-Sutton). 

Secondary  sarcoma  of  the  ovaries  is  infrequent. 

Pancreas. — The  pancreas  seldom  gives  rise  to  sarcoma  in  the 
primary  form.  However,  metastatic  growths  are  more  common, 
and  chief  among  these  are  metastases  from  melanotic  primary 
tumors. 

Parotid  Gland. — The  appearance  in  this  gland  of  pure  sarcoma 
or  of  tumors  containing  sarcomatous  elements  is  quite  frequent. 
They  may  be  purely  round-  or  spindle-celled  sarcomata.  Occa- 
sionally pigmented  sarcoma,  myxosarcoma,  chondrosarcoma,  or 
osteosarcoma  is  observed.  Sarcomata  of  the  parotid,  pure  or 
mixed,  are  to  be  classed  among  the  most  benign  of  malignant  tu- 
mors. They  are  usually  encapsulated,  slow-growing,  and  easily 
enucleated,  with  little  danger  of  recurrence. 

Retroperitoneal  Sarcoma. — This  is  the  most  common  form  of 
retroperitoneal  and  mesenteric  tumors.  They  are  usually  spindle 
celled;  lymphosarcoma,  myxosarcoma,  liposarcoma,  and  cystic 
sarcoma  have  all  been  observed.  The  tumors  appear  either  dis- 
tinctly behind  the  peritoneum  or  in  the  mesentery.  They  may 
attain  an  enormous  size.  They  are,  as  a  rule,  encapsulated;  metas- 
tases are  found  in  about  one-half  the  cases.  Retroperitoneal 
sarcomata  occur  usually  after  the  age  of  thirty  and  before  the  age 
of  fifty  years.  They  are  not  unknown  to  children. 

Spleen. — This  organ  is  among  the  rarest  structures  affected 
by  primary  sarcoma,  but  it  is  interesting  to  note  that  it  may  be 
the  site  of  origin  of  angiosarcoma.  Secondary  tumors,  though 
still  rare,  are  more  frequent  than  primary,  and  among  them 
melanotic  metastases  and  lymphosarcomata  stand  out  promi- 
nently. The  melanotic  tumors  appear  as  round,  mottled,  or  black 
nodules  distributed  throughout  the  organ. 

Testicles. — Sarcomata  of  the  testicles  occur  with  moderate 
frequency.  They  are  of  various  types;  round  celled  and  spindle 
celled  predominate.  Giant  cells  are  often  found  associated  with 
the  latter  in  connection  with  striated  muscle-fibers.  Pigmented 
tumors  and  lymphosarcomata  are  occasionally  seen.  Cystic 
sarcomata  are  formed  by  cystic  dilatation  of  the  canals  of  the 
organ,  or  intracanalicular  sarcoma  by  invasion  of  these  canals  and 
the  formation  of  nodules  in  them.  Adenosarcoma,  adenocysto- 
sarcoma,  and  carcinosarcoma  may  be  found.  The  mixed  tumors 
are  found  in  a  considerable  percentage  of  the  cases. 


SARCOMA  551 

Cases  of  angio-  and  myxosarcoma  of  the  testicle  have  been 
reported.  The  spindle-celled  tumors  are  firmer  than  the  round 
celled.  Sarcoma  of  the  testicles  may  occur  at  any  age  and  are 
often  bilateral.  They  may  amalgamate  testicle  and  epididymus 
into  an  indistinguishable  mass,  or  they  may  gradually  push  aside 
the  testicular  substance  so  that  it  forms  a  thin  ensheathing  wall. 
The  tumor  may  grow  along  the  cord,  causing  enlargement  of  it 
and  loss  of  pliability.  Sometimes,  though  rarely,  the  growth 
causes  rupture  of  the  tunica  vaginalis  testis  and  the  skin,  appear- 
ing on  the  surface  as  a  raw,  easily  bleeding  fungoid  mass — fungus 
sarcomatodes.  The  tumors  may  reach  a  large  size,  especially  if 
cystic.  Metastases  may  occur  through  the  blood,  but  lymph-node 
involvement  is  rather  the  preferred  route  of  extension,  and  is 
explained  by  the  growth  of  the  tumor-cells  into  large  lymph- 
spaces,  whence  the  cells  may  be  carried  along  the  cord  to  the  lumbar 
nodes.  The  whole  chain  of  lymph-nodes  from  the  lumbar  to  the 
upper  dorsal  may  be  invaded.  Degenerative  changes,  such  as 
fatty  or  mucoid  degeneration,  calcification,  and  hemorrhage,  are 
frequently  seen  in  sarcomata  of  the  testes.  Trauma  is  cited  as  the 
exciting  cause  of  testicular  sarcoma  hi  nearly  half  the  cases. 

Thyroid. — The  appearance  of  sarcoma  of  the  thyroid  (struma 
sarcomatosa)  is  usually  in  the  form  of  an  isolated  mass.  It  may 
be  situated  in  either  lobe  or  hi  the  isthmus.  Sometimes  it 
appears  as  a  diffuse  mass.  It  is  round,  spindle,  or  mixed 
< -riled  and  may  show  giant  cells.  Osseous  and  cartilaginous 
elements  are  sometimes  found.  The  tumors  may  grow  with 
incredible  rapidity,  and  this  is  accelerated  by  the  frequent  oc- 
currence of  hemorrhage.  Sometimes  they  grow  slowly  and  may  be 
described  as  chronic.  Still  a  third  group  may  be  mentioned,  in 
which  the  primary  growth  escapes  notice  until  the  appearance  of 
metastases.  Sarcoma  of  the  thyroid  is  slightly  more  frequent 
than  cancer.  It  occurs  sometimes  in  the  young,  and  is  more  com- 
mon in  goiter  districts;  however,  its  greatest  incidence  is  in  old 
p  >iter  cases,  in  whom  the  age  of  greatest  liability  is  between  fifty 
and  sixty  years. 

The  tumors  may  produce  lymph-node  involvement,  invade 
the  veins  and  infiltrate  the  surrounding  muscles,  the  skin,  or  the 
trachea  and  larynx,  or  the  growth  may  produce  compression  of  the 
trachea  or  interfere  with  the  function  of  adjacent  nerves  by  pres- 
sure or  infiltration.  Death  may  result  from  edema  of  the  glottis. 
Metastases  occur  most  frequently  in  the  lungs,  with  the  osseous 
system  -••(•( .nd  in  frequency. 

Uterus.  Sarcoma  of  the  uterus  is  usually  seen  in  the  body,  less 
fmpientlv  arising  from  the  cervix.  In  the  body  the  tumors  arise 
either  from  the  mu-culature  or  from  the  endometrium.  Those 


552 


PRINCIPLES   OF   SURGERY 


arising  in  the  musculature  often  are  consequent  upon  myofibro- 
mata.  The  endometrial  type  is  usually  a  diffuse  growth  which 
sometimes  appears  in  the  form  of  polypi  hi  the  uterine  cavity. 
Multiple  nodules  may  be  seen  in  the  form  of  a  cluster  of  grapes. 
Discharge  of  tumor  lobules  may  take  place  per  vaginam.  The  tumor 
may  invade -the  musculature  and  widely  infiltrate  it,  passing  ulti- 
mately to  the  peritoneum.  The  muscular  types  .are  less  likely  to 
be  diffuse,  and  appear  as  roundish,  nodular  masses,  which  are  firm; 
but  when  they  are  diffuse  they  may  attain  very  great  dimensions. 
Metastases  are  not  especially  frequent.  The  tumor  on  reaching 
the  peritoneal  surface  may  invade  apposed  viscera  or  become 
widely  implanted  on  the  peritoneum.  It  is  interesting  to  note  that 
benign  tumors  of  the  uterus  may  be  invaded  by  a  sarcoma  arising 


Fig.  171. — Enormous  sarcoma  of  the  uterus.     Note  sound  in  uterine  canal. 

in  their  proximity.  Secondary  tumors  are  more  common  in  the 
vagina,  liver,  lungs,  and  bones. 

The  cervical  sarcomata  are  very  apt  to  appear  as  polypi  and 
bunched  like  grapes;  they  are  occasionally  edematous.  They  are 
usually  spindle-  or  giant-celled  tumors,  and  are  soft,  growing  with 
great  rapidity.  They  are  very  apt  to  recur  locally  after  removal, 
and  when  they  protrude  into  the  vagina  their  surface  may  become 
raw  and  cause  a  foul  suppurative  discharge.  Myxosarcoma,  ad- 
enosarcoma,  carcinosarcoma,  and  lymphangiectatic  sarcoma  have 
been  found  occasionally. 

Cut-surface  Appearance. — The  appearance  of  sarcomatous  cut 
surfaces  is  variable  on  account  of  the  great  variety  of  structure, 
and  owing  to  the  accidents  and  degenerative  changes  to  which  they 


SARCOMA  553 

are  subject.  The  surface  is  white  or  gray  or  reddish  gray  in  the 
majority  of  cases  and  may  show  a  suggestion  of  translucency. 
In  the  firmer  tumors  the  cut  surface  is  more  nearly  white.  If 
melanin  is  present  in  considerable  quantity  the  surface  is  mottled 
or  brown  or  black.  Hemorrhages  into  the  substance  of  the  tumor 
are  very  common;  they  may  be  minute  and  numerous,  or  large, 
causing  a  very  characteristic  discoloration  of  the  surrounding  tis- 
>ur<.  The  multiple  minute  hemorrhages  give,  too,  a  mottled  ap- 
pearance which,  owing  to  its  consistency  and  color,  will  not  be 
readily  confused  with  melanotic  spots.  The  cystic  tumors  present 
sometimes  walls  of  such  thickness  and  appearance  as  to  leave  little 
doubt  as  to  their  true  nature;  but  in  thin-walled  cystic  sarcomata, 
which  constitute  a  considerable  percentage  of  bone-cysts,  the  true 
nature  can  be  gathered  only  by  careful  microscopic  investigation. 
The  appearance  of  bone,  cartilage,  lymphangiectatic,  telangiec- 
tatic.  or  other  ti— ues  should  not  mislead;  they  may  be  present,  but 
the  true  nature  of  the  tumor  is  to  be  sought  in  the  solid  tissue 
•unrounding  tln--e. 

Pathologic  Changes. — The  great  variety,  the  frequency,  and 
the  early  advent  of  degenerative  and  other  secondary  changes 
occurring  in  sarcomata  make  them  an  important  factor  in  their 
stui ly.  These  degenerative  changes  are  more  likely  to  occur  hi 
the  older  parts  of  the  tumor,  and  may  so  alter  it  as  to  render  it 
entirely  unlike  the  unchanged  tumor  substance.  Fatty  degen- 
eration is  common  and  may  result  in  the  formation  of  pockets 
of  fluid  (cysts)  in  the  substance  of  the  tumor.  Aside  from  myxo- 
sarcoma,  and  independently  of  it,  myxomatous  degeneration  is  a 
very  common  change,  in  which  a  mucoid  substance  replaces  the 
cells,  the  intercellular  substance,  and  the  connective  tissue. 
Tin-  can  lie  distinguished  from  myxosarcoma  by  its  appearance  in 
spots  in  the  older  part  of  the  tumor,  while  the  distribution  is 
uniform  in  myxosarcoma  and  is  coincident  with  the  formation  of 
the  cells — i.  e.,  it  is  a  part  of  the  growth.  The  degenerative 
chanues  niay  be  so  rapid,  compared  with  the  growth  of  the  tumor, 
M  to  i^ive  it  the  appearance  of  a  cyst  pure  and  simple  with  a  wall 
of  variable  thickness.  Fig.  146  illustrates  a  large  cystic  sarcoma 
in  which  the  secondary  nodules  no  larger  than  a  hen's  egg  were 
already  beginning  to  >how  cy.-t  formation  in  their  center.  Casea- 
tion  i-  said  to  have  been  observed  in  sarcomata:  it  is  probably  due 
to  the  action  of  tubercle  bacilli.  Hemorrhage  from  the  ulcerated 
surface  of  the  tumor  may  occur,  but  is  not  so  common  as  in  cases 
of  cancer.  It  is  very  common  in  the  tumor  substance,  whether 
the  tumor  has  been  traumatized  or  not.  It  may  be  hi  sufficient 
quantity  to  eau-e  Midden  enlargement  of  the  tumor,  or  be  small  and 
appear  at  various  points;  in  cutaneous  or  subcutaneous  sarcomata 


554  PRINCIPLES   OF   SURGERY 

it  may  produce  distinct  discoloration  of  the  skin.  The  hemorrhage 
may  be  absorbed  or  result  in  cysts.  It  produces  discoloration  of  the 
tumor  tissue  surrounding  it.  Suppuration  occurs  in  the  ulcerative 
cases,  and  together  with  hemorrhage  and  the  continued  serous  dis- 
charge from  such  surfaces  hastens  or  intensifies  cachexia. 

The  development  of  cartilage  or  bone  in  sarcomata  occurs 
usually  in  those  tumors  arising  from  cartilage,  bone,  or  periosteum, 
occasionally  in  structures  which  normally  have  none  of  these 
elements,  such  as  kidney,  testicle,  or  lung.  A  most  common  form 
of  ossifying  sarcoma  is  epulis. 

Prognosis. — Considered  in  a  general  way,  it  may  be  stated 
that  the  prognosis  of  sarcoma  untreated  is  altogether  bad,  although 
there  are  certain  forms  that  are  comparatively  benign.  The  time 
from  the  appearance  of  the  tumor  till  the  death  of  its  host  is,  on  the 
average,  from  eighteen  to  thirty  months,  if  we  leave  out  of  con- 
sideration the  more  benign  forms  alluded  to  above.  The  small- 
celled  tumors  are  usually  more  rapid  than  the  large  celled;  the 
small  round-celled  tumors  are  the  most  rapid,  and  may  be  of  such 
quick  growth  as  to  be  mistaken  for  inflammatory  processes. 
Giant-celled  sarcomata  are  the  least  malignant  and  the  spindle- 
belled  tumors  are  intermediate.  The  presence  of  melanin  in  a 
sarcoma  intensifies  its  malignancy  from  the  dangers  of  both 
metastasis  and  lymph-node  involvement.  Melanosarcomata  of 
very  small  proportions  and  devoid  of  symptoms  may  sink  into 
insignificance  in  comparison  with  the  widespread  and  fatal  metas- 
tases,  which  may,  indeed,  be  the  first  evidence  that  the  patient 
has  of  the  presence  of  such  a  tumor. 

There  is  a  tune  when  every  sarcoma  may  be  said  to  be  amen- 
able to  curative  treatment,  although  that  time  has  frequently 
passed  when  the  presence  of  the  tumor  is  recognized,  or  the  tumor 
may  be  so  situated  that  such  curative  treatment  cannot  be  ad- 
ministered on  account  of  its  connection  with  a  vital  organ.  So 
long  as  the  cells  of  a  sarcoma  are  confined  to  the  structure  removed 
at  operation  it  is  curable,  necessarily  with  the  sacrifice  with  it  of 
structures  of  varying  importance;  but  as  soon  as  any  number  of 
cells  have  reached  a  suitable  point  for  their  growth  and  are  in- 
accessible to  removal  the  case  may  be  accepted  as  hopeless.  All 
cases  of  metastases  and  most,  if  not  all,  of  local  recurrences  after 
judicious  removal  have  an  utterly  bad  prognosis. 

In  connection  with  the  prognosis  it  should  be  impressed  that 
one  has  no  justification  for  suggesting  a  favorable  outcome  until 
a  thorough  examination  has  been  made  of  the  whole  body. 

The  malignancy  of  tumors  appearing  in  certain  organs  and  the 
dangers  of  recurrence  in  the  paired  organs  already  mentioned  de- 
mand a  very  guarded  prognosis  when  such  structures  are  affected. 


SARCOMA  555 

The  more  benign  forms — myeloma,  epulis,  and  the  mixed 
tumors  so  frequently  found  in  the  parotid  gland — in  the  majority 
of  cases  offer,  with  reasonable  judgment  in  their  treatment,  almost 
as  good  chance  of  recovery  as  if  they  were  really  benign. 

The  outlook  of  sarcoma  is  such  as  to  require  the  physician  in 
attendance  to  keep  track  of  the  case  with  thorough  examinations 
at  intervals  of  one  to  three  months  for  a  period  of  years.  No  case 
of  sarcoma  can  be  legitimately  reported  as  cured  within  a  period 
of  three  years  from  the  date  of  treatment,  and  occasional  recur- 
rences after  the  expiration  of  this  time  raises  the  question  whether 
tlii>  limit  is  sufficiently  long. 

Treatment. — The  first  and  most  urgent  fact  in  connection  with 
the  treatment  of  sarcoma  grows  out  of  the  statement  that  the 
tumor  may  at  any  moment  become  incurable,  if,  indeed,  it  has  not 
already  done  so.  Therefore,  as  soon  as  a  questionable  tumor 
presents,  it  should  be  attended  to  with  immediate  despatch,  time 
being  taken  only  for  a  careful  preparation  of  the  patient  and  for 
positively  settling  the  question  of  malignancy.  This  duty  rests 
heavily  upon  the  physician,  owing  to  the  disposition  of  patients  to 
view  with  li  t  tie  alarm  a  tumor  that  may  have  given  rise  to  nodistress. 

The  treatment  par  excellence  for  sarcoma,  wherever  it  may  be 
situated,  provided  it  has  not  passed  all  hope  of  recovery,  is  surgical 
removal  not  only  of  the  tumor,  but  with  it  of  a  sufficiently  wide 
area  of  surrounding  tissue  to  guarantee  against  probability  of  local 
recurrence;  it  must  be  removed  in  such  a  manner  as  to  reduce  to  a 
minimum  the  danger  of  liberating  tumor-cells  which  may  escape 
into  the  circulation  or  be  left  in  the  wound.  If  the  organ  in  which  the 
.the  tumor  originates  can  be  safely  spared,  it  should  be  removed  as 
a  whole,  unless  the  tumor  be  one  of  the  more  benign  forms.  The 
lumina  of  the  vessels  supplying  the  tumor  or  the  organ  containing 
it  >hoiild  always  be  carefully  inspected  to  determine  whether  they 
have  been  invaded,  and  if  so,  they  must,  if  possible,  be  dissected 
out .  Likewise,  when  the  growth  is  of  such  a  type  or  so  situated  as 
to  render  lymph-node  involvement  probable,  the  lymphatics  should 
be  dealt  with  according  to  the  directions  detailed  under  the  treat- 
ment of  Cancer. 

It  is  true  that  sarcomata  while  yet  small  and  recent  may  be 
removal  by  wide  excision  with  a  fair  chance  of  cure;  this  plan  is 
necessarily  followed  in  many  locations,  for  example,  on  the  head, 
neck,  or  trunk,  and  may,  if  careful  judgment  is  exercised,  be  oc- 
casionally employed  in  sarcomata  of  the  extremities.  It  is  un- 
questionably safer  in  the  majority  of  such  cases  to  amputate  hiidi 
above  the  tumor,  preferable  leaving  no  part  of  the  bone  in  wliich 
the  tumor  originate-,  unle»  it  }><•  jiiant  celled  or  myeloma.  It  is 
y  to  state  that  the  treatment  of  sarcoma  of  bone  is  being 


556  PRINCIPLES   OF   SURGERY 

practised  along  much  more  conservative  lines  than  formerly,  when 
every  such  tumor  was  accepted  as  an  indication  for  a  high  ampu- 
tation; the  results  obtained,  too,  justify  the  conservative  plan. 

The  benigner  types  of  sarcoma  are  dealt  with  much  less  radi- 
cally than  the  more  rapidly  growing,  more  malignant  types.  So, 
mixed  tumors  of  the  parotid  gland  are  enucleated  with  very  great 
safety,  and  the  remaining  cavity  closed  directly  or  swabbed  out 
with  pure  carbolic  acid  or  Harrington's  solution  and  closed  or 
packed.  Epulis  requires  removal  of  the  tumor,  including  the 
mucoperiosteum  from  which  it  arises,  or  this  together  with  a  bit 
of  the  alveolus.  They  do  not  require  resection  of  the  jaw  as  other 
forms  of  sarcomata  do.  Myeloma  receives  conservative  treatment 
by  resecting  that  portion  of  the  bone  containing  the  tumor  with 
a  moderate  length  of  sound  bone  above  and  below,  and  the  perios- 
teum on  that  side  toward  which  the  growth  has  been  directed. 
The  periosteum  on  the  unaffected  surface  of  the  bone  is  left  in  hope 
of  regeneration,  or,  if  it  is  considered  unwise  to  leave  any  portion 
of  the  periosteum,  both  bone  and  periosteum  may  be  resected  and 
the  defect  repaired  by  immediate  or  future  grafting  or  osteo- 
plasty. This  plan  is  not  only  applicable  to  giant-celled  tumors 
and  myeloma,  but  is  being  successfully  employed  hi  the  less 
malignant  of  other  types.  Further  than  this,  it  may  occasion- 
ally be  justifiable  to  remove  the  tumor  substance  as  if  it  were 
so  much  necrotic  bone,  by  scoop  and  curet,  and  cauterize  the 
cavity  with  carbolic  acid  and  pack  or  close  to  heal  by  blood-clot, 
or,  preferably,  to  fill  the  space  with  bone-grafts  or  Moorhof 's  bone- 
wax  and  close.  It  must  be  clear  then  that  no  hard-and-fast  rule 
can  be  laid  down  for  the  treatment  of  sarcoma  hi  general,  since 
its  treatment  depends  upon  the  cell  type,  the  situation,  and  the 
general  behavior  of  the  growth.  One  cannot  fail  to  see  how  im- 
portant it  is,  even  admitting  the  presence  of  sarcoma,  to  know  just 
what  evidence  the  microscope  gives  of  the  degree  of  malignancy; 
otherwise  it  is  impossible  to  do  justice  to  these  cases. 

Inoperable  Cases. — By  inoperable  sarcoma  is  meant  one  that 
cannot  be  removed  without  resulting  hi  the  death  of  the  patient  or 
in  which  metastases  or  lymph-node  involvement  have  been  so 
disseminated  that  its  removal  is  impossible.  To  this  perhaps 
should  be  added  those  cases  in  which  the  patient's  general  condi- 
tion is  so  poor  that  no  radical  operation  can  be  tolerated. 

The  management  of  inoperable  sarcoma  should  be  so  directed 
as  to  give  the  patient  primarily  the  greatest  comfort  and  pro- 
longation of  life.  It  may  become  necessary  to  operate  on  such  for 
relief  of  pain,  either  by  excision  of  the  primary  growth  or  by 
neurotomy,  neurectomy,  or  avulsion  of  the  sensory  nerves  sup- 
plying the  region,  for  control  of  hemorrhage  by  excision,  or  by 


SARCOMA  557 

ligature  of  the  blood-supply.  Ulceration  and  the  consequent  fetor 
and  discharge  of  body  fluids  may  also  require  excision,  when  there 
is  no  hope  of  cure. 

The  pain  of  those  who  cannot  be  otherwise  relieved  should  be 
controlled  by  liberal  administration  of  opiates;  habit  in  such  can 
be  of  little  moment.  The  surface  infection  resulting  hi  suppura- 
tion.  decomposition,  and  fetor  must  be  controlled  by  the  local 
application  of  antiseptics  and  deodorants.  It  is  best  when  pos- 
sible to  remove  such  tumors. 

The  employment  of  Rontgen  rays  in  the  treatment  of  sarcoma 
may  be  summarily  dismissed  as  of  no  curative  value,  although 
pain  may  be  alleviated  or  controlled  by  this  means. 

Coley's  fluid,  made  from  an  admixture  of  the  toxins  (culture) 
of  streptococci  (of  erysipelas)  and  Proteus  vulgaris,  has  been  em- 
ployed hi  large  numbers  of  cases;  the  idea  was  suggested  by  the 
occasional  disappearance  of  a  sarcoma  when  it  became  infected 
with  erysipelas.  The  results  have  been  disappointing,  for  while 
occasional  cures  cannot  be  questioned,  they  are  very  few,  and 
while  others  have  been  apparently  retarded  hi  their  growth  or 
reduced  in  size,  they  have  later  on  resumed  then*  activity  with  the 
usual  result.  Coley's  fluid  should,  therefore,  be  employed  as  the 
sole  reliance  only  hi  inoperable  or  recurrent  cases.  It  may  be 
possible  to  reduce  the  number  of  recurrences  by  its  routine  ad- 
ministration after  radical  operation.  The  fluid  is  administered 
daily  or  on  alternate  days.  The  first  dose  should  be  \  to  1  minim, 
and  each  dose  increased  from  \  to  1  minhn  until  the  reaction 
is  produced,  shown  by  a  marked  rise  of  temperature,  often  ac- 
companied by  a  chill.  The  administration  must  be  subjected 
to  rigid  asepsis,  and  the  doses  should  be  given  alternately  into  the 
tumor  substance,  if  possible,  and  in  remote  parts.  It  is  superfluous 
to  add  that  this  plan  can  be  followed  only  in  a  hospital.  So  long 
as  the  tumor  decreases  in  size  the  treatment  is  continued.  Con- 
tinued growth,  failure  to  reduce  the  size  and  a  resumption  of  growth 
after  a  period  of  reduction,  while  still  under  treatment,  are  indices 
that  the  treatment  will  do  no  further  good. 

Myeloma. — Aside  from  the  condition  already  described  as 
myelosarcoma  or  myeloid  sarcoma,  we  must  notice,  in  passing, 
the  so-called  myeloma,  multiple  myeloma,  or  myelomatosis. 

Structurally,  it  has  led  to  the  belief  that  it  was  a  subdivision 
of  lymphosareoma,  although  recent  studies  have  led  many  to  the 
conclu.-iuii  that  the  condition  is  not  sarcomatous  and  that  it  does 
not  truly  belong  to  the  tumor  group.  Multiple  from  the  beginning, 
it  <!<)<•>  nnt  product-  inetastases  or  lymph-node  involvement.  The 
primary  nodules  may  appear  in  widely  separated  parts  of  the 
skeleton  at  the  same  time.  Bone  substance,  cancellous  and 


558  PRINCIPLES    OF   SURGERY 

laminated  alike,  is  absorbed,  and  spontaneous  fractures  occur  or 
deformities  of  the  weight-bearing  bones  may  be  observed.  Fever 
may  be  present  and  is  intermittent.  The  condition  is  attended 
sometimes  by  pain  in  the  affected  structures.  The  presence  of 
Bence-Jones'  bodies  has  already  been  referred  to.  Besides  the 
above,  the  general  changes  in  the  blood  are  marked  and  may  be 
simply  those  of  anemia,  or  even  of  pernicious  anemia. 

Chloroma. — This  rare  tumor  is  subject  to  the  same  obser- 
vations as  myeloma,  to  which  it  is  closely  allied;  like  mye- 
loma, it  is  classified  by  some  as  a  sarcoma;  by  others,  as  closely 
akin  to  leukemia  or  pseudoleukemia.  The  tumors  derive  their 
name  from  the  presence  of  a  green  pigment  in  variable  quantity, 
giving  the  tumor  a  green  or  greenish  hue.  The  tumors  are  rare, 
and  arise  usually  in  connection  with  the  periosteum  of  the  bones 
of  the  face  and  cranium  and  with  the  spinal  column.  In  the  face 
they  are  especially  frequent  about  the  orbit.  Various  organs  in 
the  body  become  affected,  as  the  liver,  spleen,  thymus,  tonsils, 
lymph-nodes,  bones,  kidneys,  and  alimentary  tract.  The  chloro- 
matous  tissue  increases  rapidly  in  size  and  there  are  associated 
changes  in  the  blood.  The  blood-pictures  resemble  those  of 
lymphoid  or  myeloid  leukemia  or,  rarely,  pernicious  anemia. 
The  condition  occurs  in  children  and  young  adults  and  runs  a 
rapidly  fatal  course  of  from  six  to  eighteen  months'  duration. 

Endothelioma,  Mesothelioma,  and  Perithelioma. — The  tumors 
of  this  group  arise  from  the  endothelial  linings  of  the  vessels  and 
the  serous  cavities.  Their  exact  place  hi  the  classification  of  tumors 
is  not  agreed  upon,  especially  in  so  far  as  the  mesotheliomata  are 
concerned.  The  discussion  here  is  based  upon  the  belief  that  all 
the  forms  of  endothelial  cells  concerned  are  of  mesoblastic  origin. 

Endothelioma. — This  tumor  arises  from  the  endothelial  lining 
of  the  blood  capillaries  or  from  that  of  the  lymphatics.  Hence 
there  are  hemangio-endotheliomata  and  lymphangio-endothe- 
liomata.  Section  of  such  tumors  shows  groups  of  cells  arranged 
concentrically  around  the  lumina  in  whorls,  and  between  the 
various  groups  lies  the  stroma  with  a  considerable  supply  of  cells. 
The  central  area  of  the  whorls  may  be  loosely  filled  with  endo- 
thelial cells,  or  sometimes  the  lumen  is  distinctly  patent  and 
shows  blood-cells.  In  other  instances  the  whorls  fail  to  be  found 
or  appear  only  hi  certain  areas  of  the  tumor,  and  the  general  ap- 
pearance becomes  more  like  that  of  a  sarcoma. 

These  tumors  may  be  single  or  multiple;  they  grow  slowly,  and 
generally  do  not  infiltrate  surrounding  structures  and  rarely  be- 
come metastatic.  They  are  at  times  encapsulated,  or  there  may 
be  no  distinct  line  of  separation  from  surrounding  tissues.  They 
almost  invariably  behave  as  benign  tumors. 


SARCOMA 


5f>«> 


Hemangio-endotheliomata  appear  in  various  structures,  such 
as  bones,  where  they  cause  absorption  and  expansion,  or  in  the 
viscera,  but  their  most  frequent  site  probably  is  hi  connection 
with  the  dura  mater,  or  less  frequently  in  the  choroid  plexus. 
In  the  two  last-named  sites  they  are  spoken  of  as  psammomata, 
owing  to  the  fact  that  the  cells  have  undergone  hyaline  degenera- 
tion and  lime  salts  have  been  deposited,  which  can  be  recovered 
from  the  tumors  in  the  form  of  small  granules,  or  brain-sand 
(acervulus),  such  as  is  found  in  and  about  the  pineal  gland. 

Mesotheliomata. — The  word  "mesothelium"  is  employed  by 
pathologists  to  represent  the  specialized  mesoderm  which  lines 


Fin.  172. — Perithclioma  of  uterus.     The  tumor  mass  is  very  soft  and  broken 

down  at  (x). 

the  primitive  body  cavity,  and  in  the  adult  stage  lines  the  serous 
cavities,  and  the  vestiges  of  cavities  which  remain  from  the  em- 
bryonic period.  Hence  a  mesothelioma  may  be  defined  as  a  tumor 
originating  from  mesothelial  rests.  Many  of  the  tumors  which 
have  caused  so  much  confusion  on  account  of  their  transitional 
nature  are  of  such  origin.  They  may  be  of  a  distinct  adenomatous 
type  and  behave  in  accordance  with  this  interpretation,  growing 
slowly  and  causing  no  evidence  of  metastasis  or  lymphatic  inva- 
sion. In  a  lower  form  they  are  more  like  alveolar  sarcoma  or  even 
round-  or  spindle-celled  sarcoma  with  no  alveolar  arrangement. 
The  sarcoinatous  or  malignant  type  behave-  similarly  to  sarcomata 
in  growth  and  metastases,  and  in  its  fatal  termination.  Usually 


560 


PRINCIPLES   OF   SURGERY 


the  steps  of  retrogression  can  be  traced  in  these  tumors  from  the 
simpler  benign  stage  to  the  malignant  (Adami). 

The  serous  surfaces  of  the  body  may  be  the  site  of  origin  of 
mesotheliomata.  This  is  true  both  of  the  peritoneum  and  the 
pleura,  especially  the  latter.  They  are  supplied  with  a  moderate 
stroma  of  connective  tissue  and  the  cells  are  epithelioid  hi  appear- 
ance and  arranged  hi  the  form  of  a  lining  to  the  acini  of  the  tumor. 
These  tumors  are  flat  and  nodular  and  produce  a  marked  thicken- 
ing of  the  membrane,  which  may  be  mistaken  for  an  inflammatory 
product.  The  structure  resembles  that  of  carcinoma  very  closely, 
and  is  classed  as  such  by  those  who  consider  these  membranes  to 
be  of  hypoblastic  origin.  They  form  metastases  in  a  considerable  per- 


m 

Fig.  173. — Perithelioma.     (Microphotograph;  X  about  100.) 


centage  of  the  cases,  and  those  arising  from  the  pleura  produce  some- 
times large  tumors  whose  nodules  may  invade  the  lung  substance. 
Perithelioma. — The  last  of  this  group  of  interesting  growths  is 
the  perithelioma,  which  is  supposed  to  originate  in  the  endothelial 
lining  of  the  perivascular  spaces.  They  are  arranged  as  cylinders 
of  cells  which  multiply  around  the  central  capillary,  whose  proper 
endothelium  remains  unchanged.  The  cells  lie  in  rows  which  radi- 
ate from  the  capillaries.  When  the  older,  outer  cells  of  these  growths 
undergo  hyaline  degeneration  the  tumor  becomes  a  cylindroma, 
which  is  characterized  by  the  presence  of  capillaries  surrounded 
by  several  layers  of  cells  and  around  these  the  hyaline  cylinders. 


CHAPTER    XLIV 

BENIGN  EPIBLASTIC  AND  HYPOBLASTIC  TUMORS, 
PAPILLOMATA 

Definition. — A  papilloma  is  a  tumor  whose  essential  structure 
is  epithelial  (epi-  or  hypoblastic)  tissue  resting  upon  and  supported 
by  a  connective-tissue  framework.  The  framework  here,  as  in 
tumors  generally,  is  incidental,  and  develops  secondarily  as  the 
support  of  the  tumor-cells  may  demand. 

Classification. — The  subdivisions  of  papillomata  are  warts, 
pointed  condylomata  (venereal  warts),  cutaneous  horns,  soft  papil- 
lomata, and  intracystic  papillomata.  It  is  not  within  the  scope  of 
this  book  to  discuss  molluscum  contagiosum,  bilharziasis,  and 
coccidiasis,  all  of  which  may  produce  epithelial  proliferation  some- 
what resembling  papillomata.  Indeed,  it  is  necessary  to  admit  that 
warts,  venereal  warts,  and  cutaneous  horns  are  included  under  the 
heading  of  papillomata  only  in  accordance  with  long  usage,  rather 
than  from  a  feeling  that  such  a  disposition  can  be  justified  in  a 
pathologic  way. 

Warts  (Verruca  Vulgaris). — These  so-called  tumors  are  very 
common,  especially  on  the  hands  of  the  young,  although  they 
are  by  no  means  infrequent  in  the  adult.  In  the  old  they  are  often 
seen  on  the  scalp.  They  are  often  spoken  of  as  hard  warts  to  dis- 
tinguish them  from  the  true  blastomatous  papillomata  arising 
from  the  mucous  membrane.  Warts  arise  from  the  papillae  of  the 
skin,  whose  epidermal  covering  becomes  thickened  and  hard. 
The  relation  of  the  papillae  is  not  lost,  although  many  of  them  may 
IK  involved  in  the  structure  of  a  single  wart.  They  are  benign, 
slowly  growing  elevations,  sessile  or  pedunculated,  painless  except 
in  consequence  of  irritation,  and  usually  of  small  size,  rarely 
becoming  as  large  as  a  bird's  egg.  They  are  often  multiple,  so  that 
occasionally  a  child's  hands  may  be  almost  covered  with  them. 
Wart-  are  thought  to  be  due  to  some  kind  of  irritation,  a  belief 
long  held  1>\  the  laity  and  vulgarly  attributed  to  playing  with 
frogs.  They  may  occasionally,  it  is  >aid.  he  transmitted  from  one 
individual  to  another  by  contact.  The  harder,  larger,  rougher 
example*  are  ti»ure  1  and  uneven,  and  the  various  papillary 
columns  may  be  separated  from  each  other.  These,  vulgarly 
known  as  "seed-wart-."  are  much  more  likely  to  be  painful  and 
frequently  bleed.  Warts  often  come  and  go  without  discoverable 
36  .-.<u 


562 


PRINCIPLES   OF   SURGERY 


cause,  so  that  whole  groups  of  them  disappear  in  a  short  while, 
a  fact  that  renders  them  especially  amenable  to  the  conjurer's  art. 
On  the  other  hand,  they  may  persist  indefinitely,  especially  the 
larger,  hard  kind. 

Treatment. — Warts  may  be  removed  by  the  application  of  nitric 
acid,  chromic  acid,  glacial  acetic  or  trichloracetic  acid,  by  the 
galvanic  needle,  the  actual  cautery,  excision,  by  cutting  them  flush 
with  the  skin  and  cauterizing  the  base,  or  by  freezing  with  CO2 
snow.  Liquid  escharotics  should  be  employed  sparingly,  and 
applied  with  utmost  precaution  to  warts  situated  in  close  proximity 
to  the  nails,  as  the  fluid  will  encircle  the  nail  and  cause  considerable 
damage. 


Fig.  174. — Wart,  showing  epithelial  pearls.    (Microphotograph ;  X  about  10.) 

Pointed  Condylomata. — Venereal  warts,  as  they  are  com- 
monly called,  arise  in  the  region  of  the  anus,  perineum,  vulva, 
vagina,  prepuce,  and  glans  penis,  always  in  consequence  of  moist- 
ure, filth,  or  foul  discharges,  such  as  occur  in  connection  with 
venereal  diseases,  especially  gonorrhea  and  chancroids.  It  must 
not  be  assumed,  however,  that  the  presence  of  venereal  warts  is  a 
proof  of  such  a  disease.  They  are  rarely  encountered  in  the  mouth. 
They  may  be  small,  single,  and  resemble  ordinary  warts.  They 
are  often  multiple,  and  if  the  causative  irritation  and  moisture 
continue  to  stimulate  them  they  may  attain  such  enormous  size 
as  to  render  delivery  of  a  baby  impossible;  or  on  the  penis,  cover 


BENIGN  EPIBLASTIC  AND  HYPOBLASTIC  TUMORS,  PAPILLOMATA     563 

the  glans  entirely  and  give  it  a  most  bizarre  appearance.  When 
these  tumors  reach  a  considerable  size  they  are  nodulated  and 
of  uneven  surface,  resembling  a  cauliflower.  These  growths,  if 
allowed  to  remain  indefinitely,  may  become  epitheliomatous. 

Treatment. — They  usually  disappear  spontaneously  when  the 
discharge  is  controlled  and  they  can  be  kept  dry,  or,  at  any  rate, 
erase  to  grow  under  such  circumstances.  If  they  cannot  be  relieved 
in  this  way,  they  may  be  excised  as  by  circumcision  when  they  are 
on  the  prepuce.  Otherwise  they  are  to  be  dealt  with  as  warts. 
The  continued  application  of  oleum  ricini  often  entirely  relieves 
them. 

Cutaneous  Horns  (Cornu  Cutaneum). — This  rare  and  remark- 
able condition  is  seen  usually  in  the  old.  It  is  due  to  the  excessive 
development  of  the  keratinous  layer  of  the  skin  and  a  failure  of 
exfoliation.  These  growths  spring  from  the  skin,  which  does  not 
become  attached  to  the  underlying  structures,  remaining  movable. 


Fig.  175. — Venereal  warts. 

The  horns  are  extremely  hard  at  their  surface  and  internally  are 
filled  with  a  friable  substance.  They  arise  from  scars  or  healthy 
skin  or  may  be  associated  with  cancer.  The  surface  of  these 
growths  may  be  smooth  or  rough  and  warty.  They  are  usually 
single,  I  .lit  may  be  multiple,  and  are  more  common  in  women. 
Their  size  is  occasionally  astonishing,  specimens  reaching  occa- 
sionally a  length  of  10  to  12  inches  and  1  inch  or  more  in  thickness 
at  their  base.  They  may  grow  in  curved,  spiral,  or  irregular  shape. 
They  ;ire  usually  seen  on  the  face,  scalp,  back  of  the  hands,  less 
frequently  on  the  penis,  scrotum,  trunk,  and  extremities. 

Treatment.- — Removal.  They  sometimes  drop  away  without 
treatment,  especially  if  injury  or  infection  has  been  incurred. 

Soft  Papillomata.  These  growths,  together  with  the  intra- 
cystic  papillomata.  belong  properly  to  the  tumor  group.  They 
ari^e  from  the  mucous  membrane  and  grow  by  predilection  from 
the  bladder,  the  uterus,  and  the  renal  pelves,  from  the  alimentary 


564  PRINCIPLES   OF   SURGERY 

tract,  the  upper  air-passages,  and  rarely  in  the  ventricles  of  the 
brain.  The  tumors  are  sessile  or  pedunculated  nodules  or  may 
grow  into  long,  thin,  branching  processes.  The  villi  may  be  densely 
packed  in  tufts  or  may  be  less  closely  placed,  giving  a  velvety  feel. 

Unless  they  occur  in  accessible  portions  of  the  mucous  mem- 
branes they  cannot  be  diagnosed  until  the  time  of  operation. 
They  may  be  first  suggested  by  the  occurrence  of  hemorrhage,  and 
this  is  quite  common  in  papillomata  of  the  urinary  bladder,  where 
they  frequently  attain  a  considerable  size  and  are  prone  to  become 
cancerous,  some  authors  maintaining  that  they  should  in  this 
particular  organ  be  acted  upon  as  if  they  were  already  malignant 
by  removing  a  segment  of  the  bladder  wall.  The  same  may  be 
said  of  those  occurring  in  the  renal  pelves.  The  villi  are  occa- 
sionally broken  away  from  the  tumor  and  pass  from  kidney  into 
bladder  and  are  voided  with  the  urine.  The  hemorrhage  ensuing 
upon  such  an  accident  occasionally  endangers  life.  The  passage 
of  villi  through  the  ureters  may  produce  renal  colic;  when  papil- 
lomata occur  in  the  renal  pelvis  they  are  often  bilateral,  and  the 
bladder  may  be  affected  in  such  manner  as  to  suggest  that  the 
tumors  have  become  transplanted  from  the  kidney  to  its  mucous 
membrane. 

Treatment. — The  treatment  of  soft  papillomata  should  consist 
in  thorough  removal  of  the  tumor  and  its  base,  and  if  the  growth 
is  extensive  the  organ  affected  or  that  portion  of  it  involved  may 
require  to  be  removed. 

Intracystic  Papillomata. — This  growth  is  a  papillary  tumor 
which  forms  from  the  lining  surfaces  of  cystadenomata.  They 
are  seen  most  frequently  in  adenomatous  cysts  of  the  ovary  or 
the  mammary  gland.  They  may  also  be  found  in  the  liver  and  the 
kidneys. 

Intracystic  ovarian  papillomata  grow  hi  the  shape  of  warts, 
as  cauliflower  or  arborescent  figures,  or  may  be  nodular.  They 
are  reddish  or  white  in  color.  They  rarely  arise  from  the  outer 
surface  of  the  cyst  wall.  The  tumors  are  bilateral  in  more  than 
half  the  cases  and  often  attain  large  dimensions.  They  frequently 
cause  a  rupture  of  the  cyst  wall  and  grow  through  the  rent  into 
the  general  peritoneal  cavity.  The  tumors  often  become  can- 
cerous. 

Treatment. — Removal  of  the  cyst  or  organ  in  which  the  tumors 
arise. 


CHAPTER    XLV 

ADENOMA 

AN  adenoma  is  an  epithelial  tumor  whose  essential  structure 
is  glandular  tissue.  The  cells  of  the  tumor  imitate  the  arrange- 
ment habitually  assumed  by  the  cells  of  the  structure  from  which 
the  tumor  rests  originated.  Hence  it  is  usually  easy  to  recognize 
the  nature  and  origin  of  adenomata  even  when  heteroplastic  or 
met  astatic.  There  can,  for  this  reason,  be  no  single  type  toward 
which  glandular  tumors  tend  to  conform;  they  must  rather  be 
interpreted  in  their  relationship  to  the  various  glands  of  the  body. 


Vi\i.  17t>.     Aiiriiotihroniu  of  breast.     (Microphotograph;  X  about  50.) 

In  a  .ueneral  way  they  may  be  subdivided  into  solid  adenomata 
ami  cystic  adenomata;  tin-  latter  resulting  from  the  accident  of  at- 
tempted function  in  certain  of  the  glandular  tumors.  The  cells, 
too,  vary  as  much  as  the  cell  arrangement,  resembling  the  respec- 
tive cells  t'n>m  which  they  originate,  and  the<e  cells  may  secrete  a 
fluid  somewhat  resembling  the  normal  .-ecretion  of  the  type,  the 
accumulation  of  which  is  re-ponsiMe  for  the  cystic  adenomata. 

Structure.— <  ilandular  tumors  primarily  are  encapsulated 
growt  hs.  There  is  a  systematic  arrangement  of  the  acini  and  ducts 

MB 


566 


PRINCIPLES   OF   SURGERY 


of  normal  glandular  tissue  such  that  the  products  of  glandular 
secretion  are  conveyed  into  proper  outlets,  and  in  the  ductless 
glands  the  secretions  escape  into  blood-  or  lymph-channels. 
There  is  no  such  arrangement,  as  a  rule,  in  tumors,  even  when 
they  arise  in  the  midst  of  the  most  active  glands.  The  whole  of 
the  tumor — cells,  ducts,  and  secretion,  if  any  is  present — is  en- 
closed within  the  capsule,  and  hence  could  be  of  no  service  to  the 
body  even  if  the  secretion  were  normal.  Certain  adenomata  main- 
tain a  duct  connection  similar  to  that  of  the  glands  from  which 
they  spring.  But  the  line  of  differentiation  between  hypertrophy 
of  adenoid  structures  and  adenomata  is  poorly  established,  and 


Fig.  177. — Adenomatoid  hypertrophy  of  thyroid.     (Microphotograph;  X  75.) 

while  the  behavior  of  the  two  types  is  very  similar,  pathologists 
are  divided  concerning  the  identity  of  the  two  conditions.  Ex- 
amples of  adenomata  emptying  themselves  normally  are  seen  most 
frequently  in  polypoid  adenomata  of  the  alimentary  canal,  in 
those  of  the  upper  air-passages,  and  in  adenomatous  prostatic 
hypertrophy.  The  relation  of  the  epiblastic  and  hypoblastic 
cells  to  the  limiting  walls  of  connective  tissue  or  basement-mem- 
branes is  the  same  as  in  normal  glands,  namely,  they  lie  within 
the  acini  and  tubules,  and  form  a  lining  to  those  spaces.  This 
lining  varies  in  thickness,  so  that  the  whole  space  may  be  filled 
with  cells  lying  layer  upon  layer,  or  if  there  be  a  secretion  present 
the  center,  of  the  space  will  be  distended  with  fluid,  resulting  in  a 


ADENOMA 


567 


ey-t  adenoma.  The  cyst  in  these  cases  may  be  simple  or  multi- 
locular,  dependent  upon  the  number  of  the  pockets  of  fluid  accu- 
mulated. The  blood-supply  is  conveyed  along  the  supporting 
eonnective-tissue  framework. 

Sites  of  Formation. — It  has  been  stated  already  that  adenomata 
may  arise  in  connection  with  or  in  proximity  to  glandular  struc- 
tures,  wherever  situated.  They  are,  as  one  might  surmise,  of  far 

iter  frequency  in  certain  glands. 

Mammary  Gland. — The  majority  of  benign  tumors  arising  in 
the  breast  are  adenomata.  The  pure  form  of  mammary  adenoma 
i>  comparatively  rare.  These  tumors  are  small  and  rarely  reach  a 


Fig.  178. — Fetal  adenoma  of  thyroid.     (Microphotograph ;  X  about  100.) 

-i/e  larger  than  that  of  a  walnut  unless  they  have  become  cystic. 
Several  small  adenomata  apparently  independent  of  each  other 
and  of  widely  varying  si/c  are  sometimes  seen  bound  together  into 
a  single  mass  by  connective  tissue.  Adenomata  of  the  breast  are 
reddi-h-.uray  or  white  in  color,  and  are  definitely  delimited  from 
the  >nmmnding  structures.  The  reddish  tumors  somewhat 
re-einlile  the  pancn-a-  in  gross  appearance.  The  usual  benign 
tumor  of  the  l>rea>t  i<  the  fihro-adcnoma  or  adenofibroma,  as  it  is 
generally  called.  The  former  name  is  probably  more  correct. 
Adenomyxoma  and  adenosarconia  are  closely  allied  growth-,  if 
we  enn-ider  the  adenomatous  tissue  as  the  more  important  from 
an  etiologic  point  of  view.  Fibro-adenoma  is  rather  frequent;  some 


568  PRINCIPLES   OF   SURGERY 

authors  have  doubted  the  existence  of  pure  fibroma,  and  others  the 
existence  of  pure  adenoma  of  the  breast,  thinking  that  hi  a  sup- 
posed case  of  either  a  continued  search  would  reveal  the  presence 
of  the  other  type  of  tissue.  Fibro-adenoma  and  adenofibroma  are 
employed  in  naming  these  tumors  respectively  according  to  the 
predominance  of  glandular  or  fibrous  tissue.  They  are  irregular, 
nodular  growths,  which  occur  most  frequently  in  women  past 
thirty  years  of  age,  although  they  are  sometimes  found  hi  younger 
women,  even  as  early  as  puberty.  They  may  be  single  or  multiple, 
are  thoroughly  encapsulated,  and  do  not  become  large,  rarely  at- 
taining the  size  of  a  golf-ball.  They  are  firm  and  usually  very 
movable.  These  tumors  are  occasionally  painful. 

Salivary  Glands. — In  any  of  the  salivary  glands  adenomata  may 
appear,  but,  as  in  the  case  of  other  tumors  affecting  these  struc- 
tures, with  far  greater  frequency  in  the  parotid.  They  occur 
rarely  even  hi  the  parotid.  The  pure  form  of  adenoma  occurs  as 
a  small,  slowly  growing  tumor,  which  is  not  very  movable.  They 
are  soft  and  more  or  less  nodular  and  may  become  cystic. 

In  the  mixed  form  these  tumors  appear  in  the  parotid  gland 
as  adenochondroma,  adenofibroma,  cystadenoma,  adenocarcinoma, 
and  adenosarcoma.  Rarely  adenomata  of  the  salivary  glands  which 
were  structurally  benign  have  gained  entrance  to  the  blood-vessels 
and  been  distributed  throughout  the  body,  producing  unques- 
tionable metastases. 

Thyroid. — Single  or  multiple  adenomata  may  develop  hi  the 
thyroid,  and  appear  either  as  congenital  or  postnatal  tumors,  thus 
constituting  one  form  of  goiter.  They  are  slowly  growing,  movable, 
benign  tumors,  and  the  individual  growths  may  attain  the  size 
of  a  fist.  They,  too,  just  as  adenomata  of  the  salivary  glands,  may 
become  metastatic,  preferring  the  osseous  system,  although  their 
remaining  characteristics  are  those  of  benign  growths.  Adenoma 
of  the  thyroid  may  become  cystic,  and  this  form  has  been  ob- 
served occasionally  to  result  in  large  cysts  of  the  gland  which 
were  ensheathed  in  a  thick  capsule  which  contains  a  greater  or 
smaller  deposit  of  lime  salts. 

Kidneys. — True  adenomata  of  the  kidneys  usually  appear  in 
the  old.  They  are  small  round  tumors  and  rarely  grow  larger  than 
a  guinea-hen's  egg.  They  are  usually  solitary  and  yellowish- 
brown  or  white  hi  color.  They  may  occasionally  be  multiple. 
There  is,  besides  the  simple  adenoma,  a  papillary  type.  The  two 
are  often  mixed.  In  the  adenomatous  type  papillary  elevations 
arise  from  the  inner  surface  of  the  tubules  and  constitute  a  tumor 
within  their  lumina.  This  type  frequently  bleeds.  Adenomata 
usually  appear  in  the  cortex. 

Alimentary   Tract. — The  mucous  membrane  of  the  stomach 


ADENOMA  569 

may  be  the  site  of  adenomata,  which  develop  as  either  adenomatous 
polypi  or  broad,  flat  tumors.  They  are  usually  small,  but  may  de- 
velop into  larger  tumor  masses,  and  are  single  or  multiple.  Kauf- 
111:11111  subdivides  them  into  simple,  cystic,  or  papillary;  in  the  latter 
they  assume  an  elongated  form,  resembling  papillomata  of  the 
mucous  membrane.  These  adenomata  are  made  up  of  the  glands 
of  the  mucous  lining,  overgrown  and  densely  packed  into  the 
tumor  mass.  Gastric  adenomata  are  capable  of  becoming  can- 
cerous or  may  appear  conjointly  with  cancer  of  the  stomach. 

In  the  intestine  the  same  forms  of  adenoma  may  appear  as  in 
the  stomach.  They  occasionally  reach  the  size  of  an  apple,  but 
are  usually  small  and  multiple;  the  tumor  may  cause  intestinal 
ol»t  ruction  by  blockage  of  the  lumen  or  become  the  caput  of  an 
intussusception,  or,  if  situated  lower  down  in  the  large  bowel, 
cause  prolapsus.  In  the  rectum  even  of  children  these  tumors  may 
appear  sessile  or  pedunculated,  and,  if  the  latter,  may  protrude 
through  the  anus  and  become  gangrenous.  Hemorrhage  from 
rectal  adenomata  is  not  infrequent,  and  they  are  unfortunately 
di>po-ed  to  become  malignant  in  addition  to  the  harm  they  do  in 
n  m.-equence  of  their  situation.  In  rare  cases  a  condition  known  as 
adenomatous  polyposis  of  the  intestines  appears,  and  is  so  universal 
in  distribution  that  the  whole  alimentary  mucosa  from  stomach  to 
anus  is  lined  with  tumors.  This  condition  in  children  may  be 
cau-ative  of  colic,  diarrhea,  and  melena. 

Uterus. — Adenomata  of  the  mucosa  of  the  uterus  can  be  classed 
with  benign  tumors  only  with  serious  question,  and  only  with  the 
understanding  that  such  classification  shall  not  obscure  the  fact 
that,  while  they  may  be  structurally  benign,  they  are  certain 
ultimately  to  become  malignant,  and  must  be  dealt  with  accord- 
ingly. Certain  authors,  indeed,  contend  that  there  is  no  such 
1 1 1 i n<4  as  a  benign  uterine  adenoma.  In  the  uterus  they  may  appear 
as  adenomatous  polypi  which  arise  either  in  the  body  of  the  uterus 
or  in  the  cervical  canal;  these  are  seldom  malignant.  On  the 
other  hand,  the  diffuse  adenoma  is  the  type  that  deserves  to  be 
dealt  with  only  as  malignant  tumors,  for  while  one  portion  may 
show  a  true  adenomatous  structure  under  the  microscope,  it  is 
prohalile  that  some  other  portion  would  reveal  unquestioned  ma- 
lignity, and  it  is  certain  that  if  left  it  will  do  so. 

Ovaries. — One  of  the  very  frequent  sites  of  adenomata  is  the 
ovaries,  a  fact  which  is  usually  lost  sight  of,  owinn  to  the  fact  that 
these  tumors  are  cystic,  or  cystadenomata.  Solid  adenomata  of 
the  ovaries  are  very  rare,  but  the  cystic  type  is  extremely  com- 
mon, and  appears  as  single  or  multiple,  as  unilateral  or  bilateral 
growths.  They  may  attain  an  enormous  >ix.-.  -pecimens  having 
been  removed  which  weighed  100  pounds  or  more,  and  cysts  con- 


570  PRINCIPLES   OF   SURGERY 

taining  several  gallons  of  fluid  are  frequently  seen.  They  are 
unilocular  or  multilocular,  and  while  usually  of  the  simple  cyst- 
adenomatous  type,  may  contain  intracystic  papillomata  (q.  v.), 
cystadenoma  papilliferum.  The  consistency  and  fluctuation  of 
cystadenomata  depends  on  the  amount  of  solid  tissue  present, 
especially  of  that  constituting  the  cyst-walls  and  separating 
the  pockets.  The  papilliferous  cysts  grow  more  slowly  and  attain 
a  much  smaller  size  than  the  simple  form. 

Liver. — Two  types  of  adenoma  appear  in  the  liver  either  inde- 
pendently or  both  in  the  same  tumor  mass.  One  of  these  types  is 
made  up  of  liver  cells  and  shows  an  imperfect  and  irregular  forma- 
tion of  acini;  while  the  second,  made  up  of  epithelium  which  lines 
the  bile  channels,  appears  to  be  formed  by  the  development  of 
numerous  closely  placed  bile  channels.  Adenoma  of  the  liver  may 
be  single  or  multiple  and  does  not  ordinarily  attain  large  dimen- 
sions. They  are  usually  well  defined  and  encapsulated,  showing  a 
definite  termination  at  the  border,  and  compressing  the  sur- 
rounding liver  structure,  a  phenomenon  which  does  not  appear  in 
hyperplasia.  The  cellular  adenoma  is  a  soft,  whitish,  yellowish- 
brown,  or  reddish  tumor  whose  cells  may  produce  bile,  and  the 
channel  or  duct  adenomata  are  often  converted  into  cystadenoma 
by  distention  with  fluid.  Adenomata  are  especially  apt  to  develop 
hi  cirrhotic  livers  where  hyperplasia  also  is  especially  well  marked, 
and  in  these  cases  the  two  conditions  can  often  not  be  differentiated 
from  each  other.  Either  form  may  undergo  malignant  change. 

Other  organs  are  occasionally  the  site  of  development  of  adeno- 
mata, namely,  the  testicle,  the  pancreas,  and  the  prostate.  How- 
ever, the  enlarged  prostate  usually  encountered  is  due  to  hyper- 
trophy rather  than  to  tumor  formation. 

Symptoms. — Adenomata  have  usually  all  the  characteristics 
of  benign  tumors.  They  grow  slowly  as  round,  encapsulated, 
movable  tumors,  and  are  found  in  glands  in  close  proximity  to  them, 
or  in  structures,  such  as  the  mucous  membrane,  which  normally 
contain  glandular  tissue.  They  are  rarely  heteroplastic.  More 
rarely  adenomata  develop  in  the  form  of  pedunculated  polypi  at- 
tached by  their  pedicles  to  the  mucous  membrane,  or  as  broad, 
flattened  growths  such  as  are  seen  occasionally  in  the  endo- 
metrium.  Adenomata  develop  usually  prior  to  middle  life,  are  of 
only  moderate  dimensions,  and  do  not,  therefore,  produce  symp- 
toms by  their  mechanical  presence.  Exceptions  to  this  statement 
are  to  be  found  in  the  intestinal  tumors,  which  serve  as  a  starting- 
point  for  intussusception  or  produce  intestinal  obstruction  by 
blocking  the  lumen  of  the  gut,  where  they  develop  in  the  rectum 
and  narrow  its  dimensions,  where,  by  their  great  number  in  the 
alimentary  tract,  they  cause  diarrhea  and  melena,  and  when 


ADENOMA  571 

occurring  in  the  uterus  they  produce  an  abnormal  menstrual  flow, 
ju-t  as  a  beginning  cancer  might.  Adenoma  is  the  only  benign 
tumor  other  than  chondroma  which  has  been  observed  to  produce 
metastasis. 

Variations. — Adenoma  is  frequently  combined  with  other  tu- 
mor elements.  Fibro-adenoma,  adenosarcoma,  and  adenocarci- 
noma  are  the  more  important  forms. 

Pathologic  Changes. — The  most  important  fact  to  be  im- 
pressed in  connection  with  adenoma  is  that  it  is  under  certain  cir- 
cumstances liable  to  become  carcinomatous,  and  hi  the  uterus  par- 
ticularly should  be  regarded  as  if  it  were  indeed  already  malignant. 
Tl lose  who  are  accustomed  to  have  microscopic  examinations  made 
of  tumors  of  the  breast  which  have  been  removed  early  know  how 
often  microscopic  evidence  of  cancerous  transformation  is  found 
in  mammary  adenoma.  This  further  statement  is  also  important, 
namely,  that  while  certain  portions  of  an  adenoma  are  unques- 
tionably benign,  no  conclusion  can  be  drawn  therefrom  that  no 
other  portion  of  the  tumor  is  malignant. 

The  other  important  change  ensuing  in  adenoma  is  the  con- 
version of  the  tumor  into  a  cystadenoma.  This  may  follow  in  any 
case  where  a  secretion  is  produced  and  no  outlet  for  it  is  provided; 
but,  as  a  rule,  the  cysts,  like  the  adenomata,  are  small.  The  case  is 
very  different  in  the  ovary,  in  which  enormous  cysts,  already  referred 
to,  form  with  very  great  frequency.  Moderately  large  cysts  are 
produced  sometimes  in  connection  with  adenomata  of  the  thyroid. 

Prognosis. — So  long  as  adenomata  remain  benign  they  do  not 
endanger  life,  and  because  of  their  small  size  cause  little  or  no 
deformity.  The  possibility  of  malignancy  developing  in  any 
tumor  of  this  type  introduces  an  element  of  uncertainty  so  long 
as  the  tumor  remains;  in  the  mammary  gland  it  is  fairly  probable 
that  such  a  tumor  is  beginning  to  show  malignant  cells  or  that 
it  at  any  time  may  do  so.  In  the  uterus  it  may  be  accepted  as  the 
b«--t  miide  that  it  positively  will  become  malignant  unless  it  is  the 
]M)lypoid  variety,  and  even  then  it  may.  The  cystic  tumors  aris- 
ing from  ovary  or  thyroid  especially  demand  interference,  owing 
to  the  distress,  danger,  and  deformity  produced  by  them.  These 
cy-tic  tumors  rarely  become  malignant. 

Treatment. — Usually  an  adenoma  may  be  removed  by  enuclea- 
tion.  but  whether  the  work  shall  re-t  here  should  be  determined  by 
the  microM-ojK'.  The  finding  of  malignant  cells  calls  for  more  radi- 
cal work.  <  >rgans  of  vital  importance,  -uch  as  the  kidneys,  should 
not  be  exci-ed  for  adenomata,  for  the  growths  are  often  bilateral;  it 
is,  therefore,  better  to  enucleate.  When  the  malignant  form 
appear-  in  the  uterus  no  other  treatment  but  hysterectomy  should 
be  done. 


CHAPTER    XLVI 

CANCER 

THE  term  "cancer"  is  employed  here  to  embrace  all  forms  of 
malignant  epiblastic  and  hypoblastic  tumors.  Those  tumors  of 
malignant  or  semimalignant  nature  arising  from  the  endothelium, 
according  to  most  teachers,  namely,  endothelioma,  mesothelioma, 
perithelioma,  and  cylindroma,  have  been  discussed  already  in 
connection  with  sarcoma.  Ribbert  and  others,  however,  claim, 
with  weighty  evidence  sustaining  their  views,  that  they  should  be 
classified  with  cancers. 

Definition. — A  cancer  is  a  malignant  epiblastic  or  hypoblastic 
tumor. 

Classification. — From  a  practical  standpoint  it  is  customary  to 
subdivide  cancer  into  epithelioma  and  carcinoma.  The  former  is 
derived  from  squamous  epithelium  or  by  metaplasia  from  the  other 
varieties,  and  the  latter  from  the  glandular  and  other  epithelial 
cells  not  of  the  squamous  type.  Carcinomata,  therefore,  originate 
from  those  structures  which  contain  glands  or  gland-ducts,  and 
arise  in  organs  containing  the  non-squamous  cells.  In  a  word, 
epithelioma  arises  from  non-functionating,  while  carcinoma  arises 
from  the  functionating,  epiblastic  and  hypoblastic  cells,  a  fact  that 
reminds  one  strikingly  of  the  relationship  sustained  by  hard  warts 
and  adenomata  to  the  same  cell  types  respectively. 

Clinical  Classification. — 

1.  Epithelioma. 

0    p,  /  (a)  Soft,  medullary,  encephaloid,  or  acute. 

— .  v^arcmoma      \  /-,\  TT     »       .    ,  •,       . 

(  (o)  Mard,  scirrhous,  or  chronic. 

Ribbert's  Classification. — 

1.  Squamous-celled  cancer,  distinguished  by  the  presence  of 
cornifying  epithelium. 

2.  Glandular   skin-cancer,   which   does   not   show   cornifying 
cells  and  is  related  to  the  skin  glands  (cylindroma). 

3.  Cylinder-cell  cancer,  in  which  the  epithelioma  is  arranged 
in  the  shape  of  glandular  ducts. 

4.  Glandular    cancer,    which    originates   from    the   glandular 
(functionating)  epithelium. 

Some  of  the  classifications  give  also  a  colloid  type  of  carcinoma 
which  really  appears,  but  the  colloid  condition  is  incidental,  hence 
it  is  omitted  here. 

572 


CANCER  573 

Etiology. — The  subject  of  the  causation  of  cancer  has  been 
mo-t  exhaustively  and,  one  might  add,  fruitlessly  studied  during 
the  last  decade.  We  are  to-day  where  we  were  at  the  beginning, 
in  total  ignorance  except  in  so  far  as  most  men  believe  that  failure 
along  certain  lines  has  convinced  us  that  the  cause  lies  not  there. 

When  the  real  relation  of  bacteria  to  so  many  diseases  was 
established  and  their  possible  etiologic  relation  was  suspected  or 
accepted  hi  many  others,  hope  was  widely  stimulated  that  the 
cause  of  cancer  might  be  sought  and  found  in  the  form  of  an  ex- 
traneous parasite.  Various,  numerous  claims  have  been  made, 
only  to  be  overthrown;  and  although  the  work  still  continues  in  a 
few  laboratories,  the  search  for  a  bacterial  cause  has  resulted  largely 
only  in  the  conviction  of  the  majority  of  the  profession  that  cancer 
is  not  of  parasitic  origin.  There  is  much  other  evidence  that  it 
is  not  produced  in  this  way,  as  a  close  study  of  the  origin,  growth, 
and  behavior  of  cancer  cells  will  show. 

The  view  most  widely  held  and  supported  by  the  most  accurate 
pathologic  work  is  that  cancers  originate  similarly  to  other  tumors, 
namely,  from  pre-existing  cells  of  the  body.  In  these  pre-existing 
cell-  there  must  be  an  innate  capacity  to  multiply  rapidly  and 
indefinitely  (hence  the  greater  tendency  of  embryonic  analgen  to 
jinx  luce  cancers),  a  stimulant  to  excite  this  innate  tendency  to 
action,  and  such  conditions  present  as  will  favor  their  growth  hi  a 
typic  malignant  fashion,  namely,  to  infiltrate  tissues  whose 
normal  function  embraces  the  restriction  of  those  very  cells  to  a 
definite  po.-ition  in  the  body.  It  is  thought  that  cells  which  are  not 
embryonic  may  be  caused  to  develop  into  cancer,  but  universally 
admitted  that  the  embryonic  cells  show  much  greater  adaptability 
for  the  necessary  requirements. 

Ribbert's  view  of  the  origin  of  cancer,  based  upon  an  exhaustive 
study  of  beginning  tumors  ("Karzinom  des  Menschen"),  is  that 
the  tendency  to  indefinite  proliferation  must  be  present  in  the  epi- 
blastic  or  hypoblastic  cells  from  which  the  tumor  arises,  that  a 
stimulus  must  call  forth  their  multiplication,  and  that  the  limiting 
basement-membrane  must  be  acted  upon  in  such  a  way  as  to  admit 
the  growth  of  the  epithelial  cells  through  it  into  the  tissues. 
These  two  conditions  he  finds  in  the  action  of  slow  irritants  which 
produce  a  mild,  chronic,  not  necessarily  infective,  inflammation, 
caused  often  by  the  failure  of  the  tegumentary  cells  to  throw  off 
their  secretions  normally.  This  irritation  stimulates  the  epithelial 
eells  to  a  greater  activity  and  destroys  or  damages  the  basement- 
nieinlirane  to  such  an  extent  that  it  can  no  longer  resist  the  inward 
growth  of  cells,  which,  if  the  connect ive-t i— ue  -ulMratum  remained 
intact,  could  only  heap  themselves  up  into  a  non-malignant  growth. 
This  inflammatory  process  Ribbert  finds  constantly  present  in 


574  PRINCIPLES   OF   SURGERY 

beginning  cancers,  the  majority  of  those  studied  being  naturally 
skin-cancers,  owing  to  the  impossibility  of  obtaining  beginning 
cancers  of  the  deeper  structures. 

What  is  known  definitely  and  positively  accepted  concerning 
the  etiology  of  cancer?  First,  that  chronic  irritation  is  unmistak- 
ably and  often  a  predisposing  cause;  second,  that  it  is  prone  to 
arise  in  connection  with  certain  pathologic  conditions,  which  in 
their  turn  may  be  caused  by,  or  be  the  source  of,  or  render  the  part 
more  susceptible  to,  irritation. 

While  trauma  plays  an  important  part  in  the  history  of  sarcoma, 
irritation,  prolonged,  repeated,  or  continuous,  sustains  unquestion- 
ably an  equally  definite  relation  to  cancer,  which  proves  beyond  a 
doubt  that  even  if  embryonic  vestiges  or  normal  adult  cells  are 
capable  of  producing  cancer,  they  may  never  harm  their  host 
unless  irritated  into  activity.  There  are  numerous  illustrations 
of  the  sequence  of  cancer  upon  an  irritant,  more  numerous,  natu- 
rally, among  those  found  on  the  surface  and  at  the  apertures  of  the 
body. 

The  frequency  of  cancer  of  the  lower  lip  in  men  and  its  paucity 
in  women  is  attributed  to  the  fact  that  men  smoke  or  use  tobacco 
otherwise;  and  the  continued  irritation  of  tobacco,  of  the  pipe- 
stem,  and  the  heat  are  responsible  for  the  difference.  The  lower 
lip  is  almost  invariably  affected,  because  it  is  pressed  against  the 
pipe-stem  in  supporting  or  shifting  the  pipe. 

Cancer  of  the  tongue  is  often  consequent  upon  irritation  caused 
by  improperly  kept  teeth,  the  jagged  or  sharp  edges  causing  a 
constant  irritation  of  the  mucous  membrane  until  a  perverted 
growth  of  cells  is  established.  It  is  also  more  frequent  in  tobacco 
chewers.  A  singular  form  of  cancer  resulting  from  irritation  is 
found  in  the  case  of  English  chimney-sweepers,  among  whom 
nearly  50  cases  of  cancer  of  the  scrotum  have  been  reported.  The 
condition  is  not  found  elsewhere.  The  chronic  irritation  by  soot  is 
assigned  as  a  cause.  Other  cases  of  irritation  cancer  are  recorded 
due  to  the  action  of  tar  and  paraffin.  Probably  an  important  ex- 
planation of  the  frequency  of  cancer  at  the  pylorus,  the  ileocecal 
region,  and  the  rectum  and  anus  is  that  these  are  the  points  of 
greatest  irritation  in  the  alimentary  tract. 

One  of  the  most  distressing  and  apparently  certain  irritative 
causes  of  cancer  is  the  prolonged  action  of  re-rays.  It  occurs  chiefly 
among  physicians  who  allow  themselves  to  come  within  the  field. 
The  skin  becomes  irritated,  rough  and  fissured,  and  the  nails 
unhealthy;  keratosis  develops  and  at  variable  periods  thereafter 
one  or  several  cancers  develop.  The  cancer  often  appears  long 
after  cessation  of  causative  exposures. 

Scars  sometimes  serve  as  a  starting-point  of  cancer.     These 


CANCER  575 

may  be  situated  either  on  cutaneous  or  mucous  surfaces.  Mar- 
joliifs  ulcer  is  an  ulcer  found  in  a  pre-existing  scar  and  is  in  the 
majority  of  cases  epitheliomatous.  The  source  of  the  cicatrix 
is  immaterial;  it  may  be  traumatic  or  result  from  decubitus, 
ulcers,  burns,  or  other  causes.  The  frequency  of  cancer,  either  in 
the  cicatrix  of  healed  ulcer  of  the  stomach  or  even  before  healing 
occurs,  stands  out  prominently  in  the  history  of  gastric  cancer,  while 
the  influence  of  cervical  scars  resulting  from  laceration  during 
labor  has  become  proverbial.  The  influence  of  cicatrices  in  the 
production  of  cancer  is  not  definitely  determined,  but  the  scar 


IMR.  179.  -  Kpiilii  li  iina  of  scrotum,  showing  extrusive  lymph-node  involve- 
ment .    This  patient  has  worked  twenty-two  years  in  :i  gas  factory. 

either  produces  more  or  less  irritation  or,  owing  to  its  poor  nutri- 
tion, is  more  susceptible  to  irritants  which  are  not  sufficient  to 
incite  normal  cells  to  malignant  activity.  Neve  found  that  out  of 
17'_'()  malignant  tumors  observed  by  him  in  India,  848  were  cancers 
of  the  upper  thigh  and  abdomen  produced  from  scars  caused  by 
burns,  it  being  their  custom  to  carry  baskets  of  fire  under  their 
clothing. 

The  same  factor  of  irritation  favoring  the  development  of 
cancer  is  manife-ted  in  pathologic  processes  of  various  kind. 
Cancer  of  the  gall-bladder  is  associated  witli  gall-stones  in  at  least 
four-fifths  of  the  cases,  and  probably  even  in  a  much  higher 
percentage.  The  same  rule  obtains  relative  to  sex  in  both  gall- 


576  PRINCIPLES   OF   SURGERY 

stones  and  cancer  of  the  gall-bladder,  both  being  much  more 
common  in  women.  Fiitterer  found  209  cases  of  gall-stones  re- 
ported in  268  cases  of  cancer  and  no  mention  of  their  presence  or 
absence  in  the  remaining  59  cases.  Siegert  found  94  cases  of 
gall-stones  in  99  cases  of  gall-bladder  cancer.  The  fact  cannot, 
therefore,  be  denied  that  there  is  a  very  definite  and  almost  uni- 
form correlation  of  the  two,  and  this  can  be  explained  only  on 
the  ground  that  gall-stones  may  by  their  continued  presence  en- 
courage the  development  of  cancer. 

A  similar  condition  is  found  in  the  origin  of  cancer  of  the 
stomach  in  connection  with  or  subsequent  to  ulcer.  Ulcer  is  ac- 
cepted at  present  as  the  most  important  predisposing  cause  of 
cancer  of  the  stomach.  Graham  estimates  that  61  per  cent,  of  the 
large  number  of  cases  of  gastric  cancer  he  has  studied  were  pre- 
ceded by  ulcer.  Here  the  condition  is  the  reverse  of  that  observed 
above  in  connection  with  gall-bladder  cancer,  namely,  that  gastric 
cancer  and  gastric  ulcer  are  both  more  common  in  the  male 
sex. 

Similarly,  certain  inflammatory  or  allied  processes  may  serve 
as  the  starting-point  of  cancer;  examples  are  abundant.  Chronic 
gastritis  is  given  by  Kaufmann  as  a  cause  of  gastric  cancer. 
Likewise  the  f ollowing  cases  given  by  Ribbert  illustrate  the  point : 
cancer  developing  in  connection  with  ectopia  vesicse,  cancer  of  the 
vagina  irritated  by  wearing  a  pessary,  cancer  of  the  breast  in  which 
a  sewing  needle  was  found,  cancer  following  the  application  of 
vesicants  to  a  wound,  cancer  of  the  skin  following  the  frequent 
application  of  CO2  ice  to  lupus  erythematodes,  carcinoma  of  the 
navel  due  to  uncleanliness,  carcinoma  of  the  penis  when  the 
prepuce  is  long  in  contrast  with  its  absence  in  the  circumcised;  the 
greater  frequency  of  carcinoma  of  the  esophagus  from  the  use  of 
tobacco  and  alcohol,  and  of  the  mouth  from  chewing  tobacco  or 
betel  nuts  (as  the  Hindoos  do). 

In  leukoplakia  buccalis,  a  condition  found  in  smokers,  chewers, 
and  brandy  drinkers,  cancer  develops  much  more  frequently  if  the 
patient  is  syphilitic.  So  true  is  this  that  some  authors  claim  that 
it  occurs  only  in  syphilitics,  unquestionably  an  untenable  position. 
It  is  attributable  to  syphilis  in  about  three-fourths  of  the  cases, 
and  to  the  other  causes,  especially  tobacco,  in  one-fourth.  A 
similar  condition  is  occasionally  observed  on  the  penis  and  on  the 
vulva  (kraurosis).  The  importance  of  this  lesion  lies  in  the  fact 
that  it  plays  a  heavy  role  in  the  production  of  cancer  of  the  tongue 
and  mucous  membrane  of  the  mouth.  Of  100  cases  of  cancer  of  the 
tongue  observed  by  Bottini,  all  were  tobacco  chewers. 

The  appearance  of  cancer  as  a  sequel  to  pathologic  conditions 
occurs  in  seborrhea,  eczema,  lupus,  xeroderma,  bilharziasis,  and 


CANCER  577 

kerato~is  especially  in  the  latter  condition,  which  seems  to  be  a 
fairly  commpn  beginning  of  skin-cancer.  It  is  necessary  to  men- 
tion in  this  connection  that  the  skin  lesions  following  the  pro- 
longed use  of  arsenic  may  terminate  in  cancer. 

The  origin  of  cancer  from  moles,  papillomata,  adenomata, 
dermoid  cysts,  and  unobliterated  vestigial  fetal  structures  is  prob- 
ably subject  to  the  influence  of  irritation  just  the  same  as  in  the 
normal  and  pathologic  structures  already  discussed,  with  the 
additional  tendency  of  the  more  lowly  organized  cells  constituting 
th«'in  to  assume  an  unnatural  growth.  That  is,  the  cells  of  these 
structures  are  more  embryonic,  hence  more  susceptible,  than 
normal  cells. 

Structure. — In  order  to  present  the  structure  of  cancer  in  a 
char  manner  it  is  necessary  to  preface  the  discussion  of  this  sub- 
ject with  a  few  fundamental  observations:  First,  a  strict  inter- 
pretation of  the  word  means  that  cancer  is  a  malignant  tumor 
made  up  of  masses  of  epiblastic  or  hypoblastic  cells  and  of  nothing 
else.  Whatever  else  may  be  present  in  a  gross  specimen  of  cancer 
is  only  accidental  or  incidental,  but  it  is  not  cancer,  whether  it  is 
connective  tissue  or  blood-vessels  of  new  formation  or  normal. 
These  incidental  findings  may  be  the  direct  outcome  of  the  presence 
of  cancer  in  the  tissues,  and  are  often  of  great  value  in  conveying 
information  to  the  pathologist,  microscopist,  or  diagnostician; 
but  it  must  be  emphasized  that  they  are  no  part  of  the  cancer,  but 
are  secondary  results.  The  second  item  is,  that  cancer  grows 
directly  and  continuously  from  the  cancer  cell  or  cells  which  orig- 
inated it  and  only  by  the  multiplication  of  these  cells.  There  is 
no  accession  to  its  substance,  no  acceleration  of  its  growth  by  the 
change  of  adjacent  cells  into  cancer  cells.  It  grows  as  a  parasite 
in  the  tissues  and,  indeed,  is  a  parasite  so  far  as  its  behavior  and 
its  local  and  general  attitude  toward  the  tissues  and  the  well-being 
of  the  body  is  concerned.  There  may  be  more  than  one  primary 
cancer,  coincident  or  successive,  but  they  sustain  no  causative 
relation  to  each  other,  and  all  the  cancer  cells  which  ultimately 
appear  in  even  the  worst  cases  are  the  direct  progeny  of  the  original 
group,  not  cells  that  have  become  cancerous  under  the  influence  of 
already  pre.-ent  cancer  cell>.  Third,  the  first  step  in  the  growth  of 
cancer  reco<rni/able  }>\  the  microscope  is  the  downward  growth  of 
cells  into  and  through  the  normal  limiting  connect ive- tissue  mem- 
lirane.  Thi>.  Kibbert  and  others  claim,  is  always  antedated  by  an 
inflammatory  process,  which  on  the  one  hand  has  stimulated  t he- 
activity  of  the  essential  cells,  and  on  the  other  impaired  the  limit- 
ing properties  of  the  ba>ement  membrane  so  that  the  cells  may 
tran-.mvxs  their  limits  and  become  "in-ane  cells."  The  processes 
which  led  up  to  this  point  may  have  been  long  and  tedious,  but  the 

.'57 


578 


PRINCIPLES   OF   SURGERY 


condition  was  not  cancerous  until  the  cells  gained  their  way  through 
the  subjacent  connective  tissue.  Once  this  barrier  has  been  passe*  I, 
the  development  of  a  definite  cancer  occurs. 

With  the  above  facts  before  us,  we  may  proceed  to  study  the 
structure  of  cancer.    So  far  as  its  gross  appearance  is  concerned 


Fig.  180. — Beginning  cancer  of  the  lip,  showing  marked  cellular  infiltration 

(Ribbert). 

cancer  is  the  most  variable  of  tumors,  and  presents  for  the  indi- 
vidual tumor  no  characteristic  size  or  shape.  It  may  appear  dis- 
tinctly and  unquestionably  as  a  tumor,  or  it  may  appear  so  unlike 
a  tumor  as  to  offer  little  suggestion  of  its  true  nature.  Ribbert 
says  on  this  point  ("Karzinom  des  Menschen") :  "It  forms  large, 


Fig.  181. — Beginning  cancer  of  the  lip,  showing  the  epithelial  cells  lying 
under  a  horny  mass,  and  growing  into  the  connective  tissue,  which  shows 
cellular  infiltration  (Ribbert). 

often  very  extensive  tumors,  or,  on  the  other  hand,  not  seldom 
only  small  ones  after  long  years  of  duration;  it  appears  in  the  form 
of  a  round  or  irregular  mass,  often  with  prolonged  extensions;  it 
spreads  hi  nodular  form  over  the  skin  or  mucous  membrane,  on 
which  it  grows  with  especial  readiness;  or  it  disintegrates  prefer- 


CANCER 


579 


ably  from  its  free  surface  to  a  greater  or  shallower  depth,  so  that 
defects  exiM  which  resemble  ulcers;  it  has  sometimes  a  soft,  some- 
times a  firm,  or,  again,  a  very  hard  consistence,  a  grayish-white, 
marrow-like,  or  in  the  hard  parts  a  fibrous  cut  surface,  or  it  shows 
a  translucent  glossy  quality.  The  tendency,  when  circumstances 


S 


1  ML:   1 S2.— Beginning  cancer  of  the  lip.     Intense  cellular  infiltration  (Ribbert). 

are  favorable,  is  for  cancer  to  grow  in  a  roundish  form,  but  circum- 
stances interrupt  this  tendency  here  more  than  in  any  other 
tumor." 

Cancer  is  a  non-encapsulated  tumor.    It  may  be  safely  stated 
that  it  never  is  encapsulated  and  rarely  would  ever  show  a  sugges- 


.  183.—  Same  as  Fig.  182.     The  c-pith.-li:il  n-lls  lie  in  insular  groups  and 

in  the  infill  niit-,1  tissue  (Ril.l 


turn  of  a  pseudocapsule.  The  only  exception  to  this  i-  to  be  found 
in  tho-e  cases  where  cancer  originates  within  an  already  encap- 
Milated  tumor  and  has  not  yet  had  time  to  grow  through  it. 
The  cut  surface  of  cancer  shows  on  scraping,  curetting,  or  squ«  •»•/- 


580 


PRINCIPLES    OF   SURGERY 


ing  a  peculiar  milkish  looking  fluid  known  as  cancer  juice,  which 
is  considered  a  very  important  macroscopic  characteristic.  The 
tumor  shows  either  a  fairly  uniform  structure,  aside  from  de- 


Fig.  184. — The  very  early  stages  of  beginning  cancer  of  the  skin,  show- 
ing the  epithelial  cells  invading  the  connective  tissue,  which  is  markedly  in- 
filtrated (Ribbert). 

generative  changes,  or  bears  evidence  of  harder  connective-tissue 
sections  between  which  lie  the  more  cellular  portions.     Sections 


Fig.  185. — Growth  of  cancer  masses  of  loose-lying  cells  into  the  infiltrated  con- 
nective tissue  (Ribbert). 

of  the  tumor  or  of  the  tissues  adjacent  to  it  by  compression  yield 
worm-like  strings  of  cancer  tissue  if  the  region  is  abundantly  sup- 


CANCER 


581 


plied  with  lymphatics,  as,  for  example,  the  urinary  bladder.  The 
bio.  H  1- v.-ssels  of  cancer  are  abundant  naturally  in  the  rapidly  grow- 
ing tumors,  and  in  the  chronic  scirrhous  types  are  very  meager. 
They  are  more  perfectly  developed  than  those  of  sarcoma.  They 
have  no  definite  arrangement  and  are  thereby  unfit  to  take  care 
of  the  circulation  of  the  tumor  in  a  normal  way,  a  fact  that  will 
need  to  be  borne  in  mind  in  the  discussion  of  degeneration  of  the 
(.in nil  older  parts  of  the  tumor,  while  the  newer  peripheral 
I  tort  ions  are  growing  actively. 

It  has  been  stated  already  that  cancer  is  a  non-encapsulated 
tumor.     More  than  this,  it  shows,  when  fully  developed,  more 


Fin    1st'..— Papillary  carcinoma  of  urethra.     (Microphotograph;  X  about  50.) 

eon.-tant  clinical  evidence  of  want  of  capsulation  than  any  other 
tumor.  ..\\iim  to  the  fact  not  only  of  its  immobility,  but  of  the 
indefiniteness  of  its  outline-:  one  cannofr  say  just  where  normal 
tk<ue  ends  and  where  tumor  begins.  The  same  idea  is  conveyed 
by  examination  of  gn»-  M-ctions  of  the  tumor  together  with  the 
surrounding  normal  tissue;  for  while  the  substance  of  the  tumor 
may  abut  at^ain-i  normal  tissue,  the  rule  i>  that  there  is  gross  evi- 
dence of  its  extension  by  finder-like  proces-.-  into  the  Mirroundinjj 
structure-,  and  the.-e  processes  iiradually  become  -mailer  and  finally 

imperceptible, 

The  minute  -tructure  of  cancer  is  very  varied  and  very  inter- 


582 


PRINCIPLES    OF   SURGERY 


Fig.  187. — Epithelioma,  showing  pearls.     (Microphotograph;  X  about  50.) 


Fig.  188. — Carcinoma,  showing  large  cells.     (Microphotograph;  X  about  250.) 

esting.    The  only  general  statement  of  the  facts  is  covered  by  say- 
ing that  the  epithelial  cells  of  cancer  grow  without  rule  or  reason. 


CANCER 

with  different  arrangement  of  the  cells  in  accordance  with  the 
>ource  or  type  of  cell  from  which  the  tumor  originated  and  the 
accidents  of  growth.  Hence  one  cancer  is  made  up  of  cells  largely, 
with  relatively  little  connective  tissue,  another  of  connective 
ii— ue  and  a  great  paucity  of  cells,  with  all  grades  between  the>e 
t  wt  i  ext  i vines.  The  arrangement  of  the  cells  may  be  diffuse  and  in 
accordance  \\ith  no  plan,  similarly  to  the  arrangement  usually  seen 
in  -arcoma,  or  into  alveoli  so  far  as  the  microscopic  appearance 
shows;  serial  sections,  however,  show  that  these  alveoli  are  trans- 


I  iu.   Is'.i.— Kririmiirm  rpitln-lioiiKt  <>f  tongue.      (Mirrophotonraph;  X  12.) 


-eetion>  of  cancer  prore->e>  which  communicate  with  each 
other,  and  altogether  go  to  make  a  cancer  mass  through  which  the 
connective  ti»ue  run>.  So  that  if  the  connective  tissue  could  be 
removed  it  would  leave  a  sponge-like  mass  of  cancer  cells.  Other- 
are  arranged  in  solid  masses  of  cells  which  surround  lumina  repre- 
-enting  the  tubular  glands,  for  example,  those  of  the  skin,  to  which 
the  anlagen  historically  belong.  These  lumina  may  appear  with 
fairly  uniform  distribution  or  only  occasionally,  the  growth  of 
cells  filling  in  the  majority  of  the  lumina.  Again,  in  the  duct  or 
cylinder-cell  type  the  same  kind  of  arrangement  may  be  observed. 


584 


PRINCIPLES   OF   SURGERY 


Fig.   190. — Epithelioma.     Note  arrangement  of  cells  in  cylindroid  masses. 
(Microphotograph;  X  about  75.) 


Fig.  191. — Tubular  epithelioina  of  neck.     (Microphotograph;  X  about  100.) 


CANCEK 


5S5 


where  the  typic  arrangement  is  the  growth  of  channels  lined  with 
cancer  cell>,  which  are  usually  several  layers  deep,  but  may  con- 
sist of  a  single  layer.  Of  course,  here  too  the  growth  of  cells  may  be 
such  as  to  obliterate  the  lumen.  In  the  glandular  types  of  cancer 
the  glandular  structure  is  more  or  less  imitated,  but  marked 
variations  appear  even  hi  the  same  tumor.  In  the  instance  of  can- 
cer <>f  the  breast,  for  example,  the  glandular  arrangement  may  be 
almost  perfectly  followed,  showing  distinct  lumina;  in  another  the 
alveoli  are  filled  with  cells,  although  its  arrangement  would  indi- 
cate its  alveolar  character,  and  yet  again  the  lumen  is  present 
and  partially  or  completely  traversed  by  epithelial  cell  processes 


Fig.  192. — Mucous  carcinoma.     (Microphotograph;  X  about  100.) 

growing  across  it  from  the  alveolar  wall.  It  must  not  be  gathered 
from  the  above  that  cancer  of  a  given  structure,  even  though 

primary,  mu.-t  conform  to  the  arrangement  found  t here,  but  to  that 
of  the  structure  to  which  the  cancer  cells  normally  belong;  for 
in-tance.  a  careiuoma  of  the  ovary  may  develop  a  structure  and  be 
of  a  cell  type  entirely  unlike  anything  found  in  the  normal  ovary. 
1  hey  are  -ujipo-ed  to  originate  from  emhryomata  contained  in 
thi<  organ. 

In  squatnous-celled  cancer,  or  epithelioina,  cornification  may 
occur  and  form  concentric  ring>  of  horny  substance.  The  so- 
called  cancer  perles  are  formed  in  this  way.  The  cornifying  epi- 


586 


PRINCIPLES    OF   SURGERY 


Fig.  193. — Papillary  adenocarcinoma.     (Microphotograph ;   X  about  100.) 


Fig.  194. — Adenocarcinoma  of  rectum.     (Microphotograph;  X  about  100.) 

thelium  may  be  directly  continuous  with  the  surface  epithelium, 
or  the  process  may  take  place  in  the  deeper  portions  of  the  cancer 


CANCER  587 

Mini  -how  no  connection  with  the  integument.  The  central,  older 
portion-  of  the  masses  and  processes  of  epitheliomata  undergo 
this  change  ju>t  the  same  as  the  okler  normal  epithelial  cells 
-how  it.  Thi-  rh:m«;r  i-  due  to  the  nature  of  the  cells  constituting 
epitheliomata;  consequently  they  do  not  appear  in  other  forms  of 
cancer. 

Colloid  cancer,   otherwise   sometimes    mentioned   as   mucous 

r,  is  one  in  which  the  cancer  cells  produce  a  secretion  of 

nmeus  or  a  closely  allied  substance  which  appears  in  great  or 

small    quantity,   and    which  when    abundant    necessarily    alters 


k 


&y$8JI&$&* 

»         v   •.;•  -"  :-'.yo 


FiR.  195. — Tul>ul:ir  •  •pithi-limna  of  neck.     Malignant,  showing  area  of  inflam- 
mation.    (Microphotograph;  X  about  100.) 

the  appearance  of  the  cut  surface  and  the  clinical  signs.  It  is 
found  by  far  mo>t  frequently  in  the  cylinder-cell  cancers,  although 

it  i>  occasionally  ol»>erved  in  other  forms.  They  occur  with 
«reate>t  fre<]iieney  in  tho.-e  -tructures  whose  cells  normally  secrete 
mucu>.  e-pecially  in  the  alimentary  tract. 

Scirrhonx  ninnr  is  seen  especially  in  th<-  breast,  sometimes  in 
the  stomach  or  intestines,  and  is  characterized  by  a  prevalence  of 
connective  tis-ue.  sometimes  almost  to  the  total  exclusion  of 
cancer  celU.  Instead  of  the  tumor  adding  to  the  si/e  of  the  affected 
orjian.  it  may.  by  the  contraction  of  its  new  formed  connective 
ti-- ue.  materially  reduce  the  >ixe  of  and  disfijnire  the  organ.  The 


588 


PRINCIPLES   OF   SURGERY 


growth  of  scirrhus  occurs  precisely  as  in  the  non-scirrhous  types 
of  cancer,  namely,  by  multiplication  of  cancer  cells,  but  the  con- 
traction of  the  abundantly  forming  connective  tissue  destroys 
them,  and  they  so  completely  disappear  that  they  may  not  be 
found  except  in  comparatively  widely  separated  areas.  The 
formation  of  connective  tissue  may  be  so  abundant  as  to  form  a 
dense,  hard  mass,  bearing  no  propotionate  relation  to  the  tune  it 
has  existed.  Naturally  the  older,  central  portions  of  the  tumor  are 
harder  than  the  recent  cellular  peripheral  part.  An  important 
characteristic  is  the  presence  of  elastic  connective  tissue  in  scir- 
rhus of  the  breast.  It  is  important  to  know  in  this  connection 


Fig.  196. — Epithelioma  of  scalp.     (Microphotograph;  X  about  100.) 

that  scirrhous  cancer  may  be  accompanied  by  secondary  can- 
cerous lymph-nodes  which  show  little  or  no  evidence  of  excessive 
connective  tissue. 

Giant  cells  may  form  from  the  mixed  connective-tissue  cells  in 
cases  of  epithelioma  in  the  same  manner  as  in  the  case  of  foreign 
substances  in  the  tissues.  Also  in  carcinomata  of  very  rapid 
growth  it  may  happen  that  very  large  multinucleated  epithelial 
cells  appear,  but  they  are  not  true  giant  cells.  Still  another  type 
of  giant  cells  is  seen,  and  in  rare  cancerous  tumors  they  are  so 
abundant  as  to  distinguish  the  tumor  from  the  usual  types.  The 
arrangement  of  the  cells,  their  appearance,  and  the  tendency  to 


CANCER  589 

hemorrhage  has  led  to  the  conclusion  that  they  belong  to  the 
syncytial  type. 

The  greater  the  deviation  of  the  cells  of  a  given  tumor  from 
the  conduct  of  normal  cells,  the  greater  the  malignancy  of  the 
tumor. 

The  Growth  of  Cancer. — It  has  already  been  stated  that 
cancer  grow*  only  by  the  multiplication  of  cancer  cells,  that  the 
cells  of  adjacent  tissues  do  not  become  cancerous,  and  that  it  is 
devoid  of  a  capsule;  furthermore,  it  starts  from  cells  which  lie  on 
the  histologically  proper  surface  of  a  connective-tissue  membrane. 
one.-  the  epithelial  cells  transgress  their  membrane  and  become 
definitely  and  recognizably  cancerous,  there  is  no  limit  to  be  set 
for  their  continued  invasion  of  the  tissues  regardless  of  their 
nature.  The  cancer  cells  grow  into  the  tissues,  whether  cellular 
ti—ues,  fat,  bone,  muscle,  gland,  or  any  other  type,  by  the  ex- 
tension of  processes  from  the  initial  mass  or  by  the  escape  of  one 
or  more  cells  from  the  primary  tumor  and  their  lodgment  in  tissues 
favorable  to  their  development ;  as  the  tumor  invades  or  infiltrates 
the  normal  tissues  they  gradually  become  disintegrated  and  dis- 
appear, being  replaced  by  cancerous  tissue.  In  fatty  tissue  the 
cancer  cells  grow  among  the  fat  cells,  sometimes  surrounding 
them  >o  that  they  appear  as  microscopic  cysts,  or  occasionally 
invade  their  wall  and  fill  the  cell  cavity.  As  the  cancer  cells 
multiply  the  fat  is  obliterated.  So  it  is  that  cancer  spares  no 
structure,  whether  of  active  or  passive  function.  It  may,  in  addi- 
tion to  its  direct  destructive  action  by  infiltration  and  pressure, 
act  also  indirectly  hi  the  destruction  of  tissue,  namely,  by  de- 
stroying, collapsing,  or  blocking  the  vessels,  causing  necrosis. 
When  cancer  cells  come  into  spaces  or  cavities  they  grow  along 
the  line-  of  least  resistance  more  readily,  but  not  exclusively. 
Ilenee,  minute  processes  may  extend  along  the  anatomic  spaces 
indefinitely,  as  was  described  under  Sarcoma,  or  they  may  in- 
filtrate the  walls  of  blood- vessels  and  form  root-like  processes 
along  the  lumen  <,t  the  vessels,  blocking  them  and  favoring  throm- 
l.o-i-.  or  emboli-m,  which  latter  serves  as  the  source  of  general 
meta-ta>i-  and  is  usually  a  rather  late  occurrence;  or  (and  this  is 
very  eommon  and  may  be  very  early)  the  lymph-spaces  and 
channels  may  he  invaded  and  the  processes  grow  along  these 
i*  and  even  reach  to  other  organ*  and  produce  secondary 
tumors,  which  have  been  interpret!-.!  as  the  effect  of  enilioli  carried 
through  the  circulating  blood.  As  an  example  of  this  cancer  of  the 
stomach,  -econdary  to  cancer  of  the  breast,  may  lie  cited.  The-e 
proce>M-  e\tmd  either  with  or  against  the  direction  of  lymph- 
flow.  They  may  be  so  exceedingly  numerous  and  so  well  devel- 
oped as  to  form  a  distinct  network,  as  may  be  seen  with  the  naked 


590 


PRINCIPLES    OF   SURGERY 


eye  in  the  case  of  pleural  lymph-channels.  Among  such  network 
isolated  individual  secondary  nodules  often  appear.  It  is  such 
processes  as  these  that  can  be  squeezed  from  the  lymphatics  of  the 
urinary  bladder  or  stomach  when  cancerous.  On  reaching  a 
lymph-node  hi  the  course  of  its  extension  such  a  cancerous  lymph- 
channel  process  extends  its  cells  along  the  space  between  the  node 
proper  and  its  capsule,  the  marginal  sinus,  and  gradually  en- 
sheaths  the  lymphatic  tissue,  which  it  then  proceeds  to  infiltrate 
and  destroy.  The  capsule  is  also  infiltrated  and  becomes  at- 
tached to  the  surrounding  tissues;  it  is  as  if  a  new  cancer  had 
established  itself  in  this  region.  Now  the  cells  may  go  from  lymph- 


Fig.  197. — Metastases  of  carcinoma  in  liver.    (Microphotograph ;  X  about  50.) 

node  to  lymph-node,  extending  along  the  channel  just  as  before, 
or  they  may  escape  and  be  passed  along  as  lymphatic  emboli. 

Metastasis. — By  the  term  "metastasis"  is  meant  here,  just  as 
in  the  case  of  sarcoma,  a  secondary  tumor  which  has  formed  from 
cells  which  have  become  separated  from  the  primary  growth. 
These  cells  may  separate  accidentally  as  the  result  of  physiologic 
processes,  for  example,  by  the  blood-current,  or  as  the  result  of 
trauma.  They  are,  therefore,  favored  by  all  undue  manipulation, 
whether  for  the  purpose  of  examination  or  otherwise;  there  is  less 
danger  in  excising  for  microscopic  purposes  here  than  in  sarcoma, 
but  it  is  preferable,  when  possible,  to  use  the  same  precautions 
that  were  recommended  under  that  subject. 


CANCEH 


591 


In  cancer  the  most  common  secondary  growths  are  due  to 
invasion  of  the  lymph-nodes.  This  may  occur,  as  stated  above, 
by  direct  growth  of  the  tumor  along  the  channel,  or  from  cells 
which  have  escaped  into  the  lymph-stream  and  gone  as  emboli 
t«i  the  first  node,  where  they  are  checked  and  a  new  metastatic 
process  is  established;  later  by  one  of  these  plans  the  next  node 
is  invaded,  and  so  on.  If  the  cancer  cells  reach  the  last  node  in 
the  chain  they  may  escape  from  it  and  enter  the  blood  through  the 
thoracic  duct  or  the  right  lymphatic  duct.  The  metastatic  inva- 
sion of  lymph-nodes  is  usually  only  regional.  Retrograde  invasion 


••  -,  ••  . 

• '  J  '-4nx^-^/fXn£>t  <x»  jMaHMt 


V\v..    HK     Mrtnstasis  of  rarrinnnia  in  axillary  lymph-node.     (Microphoto- 
graph;  X  about  100.) 

of  lymph-nodes  is  probably  largely  or  wholly  due  to  the  growth  of 
lymph-channel  processes.  General  metastases  are  due  to  the 
entrance  of  cancerous  emboli  into  the  general  circulation.  They 
may  occur  through  the  lymphatics  or,  as  is  doubtless  true  in  the 
majority  of  cases,  by  invasion  of  the  blood-vessels  by  infiltration. 
Of  course,  the  site  of  most  frequent  formation  depends  largely 
on  the  veoel  through  which  the  emboli  were  admitted. 

ondary  tumor-  also  result  from  the  contact  of  a  cancerous 
surface  with  a  normal  surface,  the  latter  ultimately  becoming  in- 
vaded; from  the  escape  of  cancer  cells  into  a  serous  cavity,  as 


592  PRINCIPLES    OF    SURGERY 

pleura  or  peritoneum,  on  which  they  become  implanted  and  grow; 
from  the  contact  of  cancerous  tissue  with  the  wound  at  the  time 
of  operation.  These  two  latter  points  emphasize  the  care  imposed 
upon  the  surgeon  during  such  an  operation. 

Sites  of  Formation. — It  is  plain  from  what  has  been  previously 
said  of  cancer  that  it  can  originate  only  from  those  structures  which 
normally  contain  epiblastic  or  hypoblastic  cells,  from  those  which 
contain  them  in  the  form  of  vestiges  of  embryonic  remains,  and 
from  those  which  contain  them  by  virtue  of  some  accident  in  the 
development  of  the  fetus.  Hence  it  is  that  cancer  originates  with 
impressive  frequency  in  the  skin,  the  mucous  membrane,  and  the 
glands.  It  must  be  emphasized,  however,  that  it  does  not  arise 
from  these  sources  only,  for  embryomata,  dermoids,  and  embryonic 

r  •        -     --- 


7^\S 


Fig.  199. — Cancer  of  the  rectum. 


remains  give  origin  to  it,  as,  for  example,  in  unobliterated  gill 
slits. 

On  the  skin  they  arise  with  far  greatest  frequency  on  the  ex- 
posed surfaces,  namely,  the  hands  and  face;  they  are  rarehr  found 
on  covered  surfaces  of  the  body  except  in  consequence  of  diseased 
conditions  of  the  skin,  already  mentioned,  which  favor  their  de- 
velopment, and  in  scars.  The  penis  is  the  most  frequently  affected 
of  the  covered  parts,  and  the  anus  second.  The  factor  of  greater 
irritation  of  the  anus  and,  in  the  uncircumcised,  of  the  foreskin. 
and  the  constant  evil  action  of  uncleanly  secretions,  explains  their 
prevalence  at  those  two  sites.  On  the  face,  the  lower  lip,  the  eye- 
lids, and  the  skin  just  in  front  of  and  below  the  ear,  as  well  as  the 
ear  itself  and  the  alse  of  the  nose  are  the  usual  sites.  Cancer  of  the 
face  is  much  more  common  in  men  than  in  women  in  general, 
owing  to  their  greater  exposure  to  irritation,  and  cancer  of  the 
lower  lip  occurs  twenty  times  in  men  to  one  time  in  women. 
These  cancers  of  the  skin  often  appear  as  rodent  ulcers  or,  when 
arising  from  cicatrices,  as  Marjolin's  ulcers. 


CANCER  593 

In  the  mucous  membrane  of  the  alimentary  tract  the  sites  of 
greatest  frequency  are  the  mouth,  especially  the  tongue  of  tobacco- 
usin^  syphilitics,  the  esophagus,  the  stomach,  chiefly  at  the  pyloric 
en  1  where  ulcers  are  most  common,  the  cecum  and  appendix,  and 
tin-  rectum. 

The  pyloric  end  of  the  stomach  and  the  rectum  are  the  two 
commonest  sites  of  this  group.  In  the  genito-urinary  tract  the 
bladder  is  occasionally  invaded  and  the  uterus  very  frequently. 
Tin-  lungs  occasionally  give  rise  to  primary  cancer,  but  it  is  a 
very  rare  occurrence. 

Of  the  glands,  the  breast  stands  easily  at  the  head  of  the  list, 
while  separated  by  a  wide  disparity  are  the  prostate,  thyroid, 
salivary  glands  and  the  liver,  kidneys,  suprarenals,  pancreas, 
ovaries,  and  testicles. 

1 1  may  be  repeated  with  reference  to  cancer  that  those  organs 
which  are  least  frequently  the  site  of  primary  involvement  are 
mo-t  frequently  affected  by  metastases  (hematic). 

The  structures  affected  by  epithelioma  are  those  which  nor- 
mally contain  squamous-celled  epithelium,  and  consequently  are 
the  skin,  the  mucous  membrane  of  the  mouth,  and  the  portio 
vaginalis.  However,  the  cells  of  many  organs  either  have  the 
capart  iv  of  developing  into  squamous  cells  or  they  reach  them 
from  other  sources,  for  many  structures  which  normally  show  no 
squamous  cells  may  occasionally  give  rise  to  squamous-celled 
cancer. 

On  the  other  hand,  it  must  not  be  inferred  that  those  struc- 
tures which  habitually  give  rise  to  epitheliomata  can  give  rise  to 
this  form  of  cancer  only,  for  carcinomata  of  unquestionable  char- 
acter may  arise  from  the  functionating  epithelial  cells  contained 
in  them. 

Carcinomata  develop  with  greatest  frequency  in  the  stomach, 
tin  mammary  gland,  and  the  uterus. 

Diagnosis. — The  signs  and  symptoms  of  cancer  fall  practically 
under  two  captions — epithelioma  and  carcinoma.  This  is  espe- 
cially true  of  the  local  manifestations.  Those  features  that  are 
common  to  the  two  will  be  discussed  in  common. 

I''.l>it)nHt»i,(i.  Owing  to  the  vast  importance  of  early  recogni- 
tion of  cancer,  it  is  necessary  to  refer  to  the  appearance  of  begin- 
ning epithelioma.  The  conditions  which  so  often  serve  as  a 
starting-point  of  cancer  have  already  been  enumerated;  the 
question  that  arises  here  is  just  what  is  the  apjx'arance  of  a  begin- 
ning epithelioma,  what  evidences  >hould  lead  one  to  suspect  that 
the  condition  is  malignant.  The  feature  of  the  diagnosis  of  the 
local  condition  is  of  the  great e>t  benefit,  for  thus  early  it  alone 
serves  to  direct  the  attendant  correctly;  there  are  as  yet  no  general 


594 


PRINCIPLES   OF   SURGERY 


symptoms.  A  beginning  epithelioma  may  assume  a  variety  of 
forms;  for  instance,  it  may  start  as  a  very  thin,  small  scale  appear- 
ing on  the  surface,  which  becomes  loosened  after  a  few  weeks  or 
months,  only  to  fall  away,  leaving  the  surface  practically  smooth. 
This  may  be  repeated  a  number  of  times  and  the  scale  may  become 
gradually  larger  for  a  number  of  years,  but  producing  no  symp- 
toms other  than  possibly  a  slight  itching.  Ultimately  there  may 
appear  in  the  skin  surrounding  the  scale  small  dilated  blood-vessels 
which  radiate  more  or  less  from  it  as  a  center;  finally,  the  skin  under- 
derlying  the  scale  begins  to  thicken  and  a  definite  but  small  mass 
forms  in  the  corium.  The  same  thing  happens  occasionally  in  the 
brownish  verrucal  patches  that  form  on  the  extremities,  face,  and 


Fig.  200. — Epithelioma  of  lower  lip 
before  operation. 


Fig.    201. — Case    of    epithelioma    of 
lower  lip  (Fig.  200)  after  operation. 


scalp  of  old  people.  Again,  a  keratosis,  for  instance,  on  the  lower 
lip  remains  indefinitely,  appearing  somewhat  as  a  thin  dry  corn. 
It  does  not  come  away,  and  if  removed  without  the  underlying 
mucous  membrane  it  promptly  returns.  Exfoliation  of  the  outer 
cells  does  not  occur.  Ultimately  it  begins  to  become  thicker  at  the 
expense  of  the  underlying  tissue  and  has  become  cancerous.  The 
same  thing  may  happen  to  fissures,  warts,  moles,  eczematous  con- 
ditions, x-ray  burns,  scars,  and  leukoplakia.  It  is  the  thickening 
of  the  structures  by  the  growth  of  cells  into  the  supportive  con- 
nective tissue  which  gives  the  first  positive  evidence  of  the  true 
state  of  affairs.  The  surface  lesion  even  early  is  likely  to  be  co- 
extensive with  the  induration  produced  by  the  growth  of  cells 


CANCER  595 

into  the  subepithelial  structures.  This  extension  of  the  mass 
into  connective  tissue,  even  though  it  be  no  deeper  than  the 
curium  or  the  basement-membrane  of  the  mucosa,  is  very  valuable 
evidence,  and  should  lead  at  once  either  to  the  more  positive 
ine:m-  of  diagnosis  or  to  proper  treatment. 

The  appearance  of  epithelioma  in  the  form  of  rodent  ulcer  or  of 
Marjol in's  ulcer  should  cause  little  difficulty  of  recognition  if  the 
i  the  patient,  the  previous  history  of  the  case,  the  slow 
progress  of  the  ulcer  with  practically  no  evidence  of  healing,  and 
tin  induration  and  infiltration  of  the  tissues  more  or  less  widely 
around  the  ulcer's  margin  and  beneath  its  base  be  taken  into 
consideration. 

Kpitheliomata  are  usually  comparatively  slow  in  their  growth, 
requiring  a  long  number  of  years,  often  as  many  as  eight  to  twelve, 
to  terminate  in  death.  They  vary  in  density,  but  as  a  rule  are 
di-n-er  than  carcnimoata,  and  sometimes  are  so  hard  as  to  present 
an  almo.-t  cartilaginous  resistance  to  pressure.  The  shape  of  the 
more  common  type  of  epitheliomata  is  usually  not  spheric,  but 
more  or  less  flattened  or  occasionally  nummular,  with  edges  that 
shade  ofY  imi>erceptibly  or  unevenly  into  the  surrounding  tissue; 
sometime-  tin-  whole  ulcerated  tumor  is  raised  plateau-like  above 
the  level  of  the  skin  surrounding  it,  and  limited  by  a  hard  ring  of 
tumor  ti-sue.  Sometimes  healing  takes  place  over  a  portion  of  the 
ulcerated  surface  of  flat  epitheliomata,  but  the  ulcerative  process 
continues  to  spread  in  other  areas  and  may  return  and  attack  the 
newly  healed  Dart.  Their  tendency  to  infiltration  is  no  more 
marked,  perhaps,  but  unquestionably  much  more  frequently  de- 
mon-traMe  clinically  than  is  the  case  hi  the  deeper  tumors.  This 
manifest-  it -elf  by  the  immobility  of  the  tumor  and  the  want  of 
evidence  of  encapsulation,  but  is  especially  noticeable  when  the 
superjaeent  layers  of  tissues  are  so  bound  together  by  it  that  they 
cannot  l>e  glided  over  each  other.  For  example,  in  epithelioma  of 
the  cheek  the  growth  penetrates  to  the  mucous  membrane  and  fixes 
it  f.-i-t  to  the  underlying  tissue.  By  this  means  it  is  possible  to 
_  nize  when  infiltration  has  extended  into  an  adjacent  organ,  as 
from  uterus  or  prostate  into  the  rectum. 

There  is  a  second  form  of  epithelioma  which  assumes  a  ma.— ive, 
tumor-like  appearance  less  likely  by  far  to  confine  itself  to  the 
superficial  structure-  than  the  flat  epithelioma,  and  growing  in  all 
directions,  not  only  deeply  into  the  ti--ues,  but  rising  in  a  rather 
uneven  tumor  above  the  skin  level  and  a.— uming  roughly  a  round- 
ish shape.  Its  surface,  too,  is  often  ulcerated  and  resembles  a 
fungus  or  cauliflower  growth.  Sometimes  the  ulcerative  process 
extends  deeply  into  it-  -uli-tance  and  produces  a  crater-like 
cavity.  Moreover,  the  skin  surface  covering  it  may  be  ulcerattd 


596  PRINCIPLES   OF   SURGERY 

at  various  points  in  such  manner  as  to  remind  one  of  ulcerated 
gummata  (Kaufmann).  This  form  of  epithelioma  is  sometimes 
seen  in  vaccination  scars. 

A  special  form  of  cancer,  sometimes  assuming  the  nature  of 
an  epithelioma  and,  again,  that  of  cylinder-cell  carcinoma,  attacks 
the  nipple  primarily,  and  is  known  as  Paget's  disease  of  the  nipple. 
In  this  type  the  cancerous  process  begins  either  in  the  nipple  or  in 
the  areola  and  may  develop  into  a  broad  superficial  tumor,  or  in 
other  instances  may  grow  into  the  breast  proper  and  produce  the 
same  effect  seen  ordinarily  in  cancer  of  the  breast.  The  cylinder- 
cell  type,  of  course,  arises  from  the  lining  of  the  lactiferous  ducts. 

Paget's  disease  of  the  nipple  begins  as  an  itching,  eczematous, 
chronic  condition.  This  spreads  around  the  nipple  into  the 
areola  and  possibly  the  surface  of  the  breast.  The  nipple  ul- 


Fig.    202. — Epithelioma    of    cheek,  recurrent    after  x-ray  ''cure."      Before 

operation. 

cerates  superficially  and  gradually  shrinks  and  retracts.  The 
process  is  slow,  but,  as  a  rule,  gradually  spreads  from  the  point  of 
the  beginning.  Occasionally  the  ulceration  partially  heals  of  its 
own  accord. 

The  remaining  features  hi  the  diagnosis  of  epithelioma  are 
identical  with  those  of  carcinoma. 

Carcinoma. — Briefly  stated,  the  clinical  diagnosis  of  carcinoma 
may  be  given  in  the  following  words :  That  it  is  a  rapidly  growing 
malignant  tumor  of  very  variable  size,  whose  essential  element  is 
glandular  cells,  occurring  in  people  usually  who  are  more  than 
thirty  years  of  age.  It  is,  as  a  rule,  painless  at  the  beginning,  but 
frequently  becomes  painful  when  well  advanced  or  when  certain 
complications  arise.  It  grows  by  infiltration  and  spares  no  struc- 
ture which  it  may  reach.  It  is  never  encapsulated,  never  movable 


CANCER  597 

relative  to  the  structure  in  which  it  appears,  and,  as  it  increases 
in  size,  firmly  attaches  the  structures  affected  into  a  solid  mass. 
Tin-  shape  of  carcinoma  is  less  frequently  round  than  is  the  case 
in  other  tumors.  It  grows  flat,  round,  nodular,  or  irregular  in 
shape,  a.s  circumstances  may  determine.  Carcinoma  readily  and 
frequently  undergoes  degeneration  in  the  older  parts  of  the  tumor, 
an<  1  hence  is  very  prone  to  ulcerate.  Having  ulcerated,  hemorrhage, 
especially  if  the  tumor  is  connected  with  a  mucous  membrane,  is 
very  common  and  often  characteristic.  Infection  gains  easy  access 
to  the  degenerating  ulcerative  surfaces,  and  decomposition,  with 
foul  odors  and  discharges,  is  marked  and  extensive.  Suppuration 
is  less  common.  The  tumor  may  produce  early  or  late  lymph- 
node  involvement;  it  occurs  relatively  late  so  far  as  treatment 


Fig.  203. — Case  of  Ypithclioma  of  cheek,  shown  in  Fig.  202,  after  operation. 

(MB.  Metastases  through  the  blood  are,  as  a  rule,  late,  but  there 
arc  important  exceptions.  Cachexia  may  develop  at  any  time 
once  a  cancer  is  well  under  way;  in  uncomplicated  .cases  it  is  often 
a  very  late  and  unreliable  symptom.  The  average  life  of  patients 
who  have  soft  ean-inoinata  ranges  from  six  months  to  three  years, 
and  of  those  who  have  tumor-  with  an  abundance  of  connective 
tis>ue.  or  -cirrhoi:-  cancer-,  it  ranges  from  five  to  twenty  years. 

These  items  rnu-t  now  be  discu— rd  -eriatim.  for  no  adequate 
conception  of  the  behavior  of  cancer  can -be  gathered  from  so  brief 
a  narrative  of  it-  .-alien!  feature-. 

Rate  of  Growth. — The  broad  statement  that  carcinoma  is  a 
rapid  growth  is,  in  the  main.  true.  The  rule  is  that  it  attains  a 
given  si/e  much  earlier  than  benign  tumors  do,  but  it  does  not  at- 


598  PRINCIPLES   OF   SURGERY 

tain  so  great  a  size  as  sarcoma  or  many  of  the  benign  tumors.  It 
is  rare,  indeed,  for  one  to  find  a  single  carcinoma  of  the  size  of  a 
human  head.  On  the  other  hand,  we  do  not  infrequently  meet 
with  carcinomata  in  the  form  of  scirrhus  which  actually  reduce 
the  size  of  the  organ  in  which  they  exist,  although  a  definite  tumor 
is  found,  as,  for  instance,  in  scirrhus  of  the  breast.  Again,  the 
primary  tumor  may  be  so  insignificant  in  size  as  to  fail  to  produce 
symptoms  or  physical  signs  which  could  possibly  direct  attention 
to  the  structure  containing  the  tumor,  and  only  the  secondary 
growths  come  to  light,  until  a  postmortem  reveals  the  site  of  the 


Fig.  204. — Epithelioma  requiring  removal  of  ear,  parotid  gland,  and  much 

surrounding  tissue. 

primary  tumor.  Such  tumors  have  been  found,  for  instance,  in 
the  bile-channels  and  in  the  prostate.  Hence,  while  on  the  whole 
it  is  true  that  cancer  is  a  rapidly  growing  tumor,  it  must  always 
be  borne  in  mind  that  it  may  be  slow  growing  and  small;  and  in 
certain  instances  bear  so  little  semblance  to  a  tumor  or  be  so  ob- 
scured by  accidents  that  have  befallen  it  as  to  render  it  impossible 
to  surmise  in  a  clinical  way  that  it  is  a  tumor  at  all. 

Surface  Appearance. — The  surface  appearance  of  carcinoma  is 
of  value  only  when  the  tumor  has  invaded  the  skin  or  mucous  mem- 
brane or  when  ulceration  has  occurred.  In  the  former  instance 


CANCER  599 

the  surface  is  likely  to  be  red,  but  it  is  not  necessarily  so,  and  has 
usually  a  more  or  less  nodular  appearance.  When  ulceration  has 
occurred,  one  of  two  conditions  is  present:  either  the  surface  is 
covered  with  decomposing  tissue  and  debris,  or  if  it  is  clean  the 
tumor  may  show  a  red,  granulating  cauliflower  mass,  from  either 
of  which  there  is  a  discharge  of  serous,  sanious,  serosanguinolent, 
in  -ometimes  purulent  fluid.  The  surfaces  presenting  the  cauli- 
flower appearance  are  indicative  of  actively  growing  tumor  ele- 
ments and  usually  bleed  very  easily  and  freely,  especially  on 
manipulation. 

Consistence. — The  consistence  of  carcinoma  varies  with  its 
structure.  The  greater  the  quantity  of  tumor  cells  relative  to 
-troma,  the  softer  the  tumor.  These  tumors  cut  easily  and  may 
be  so  soft  and  succulent  as  to  be  fluctuant.  On  the  contrary,  the 
greater  the  quantity  of  connective  tissue,  the  harder  and  less 
fluctuant  the  tumor.  Some  of  these  cases  have  a  distinct  leathery 
or  even  cartilaginous  feel.  The  presence,  too,  of  cysts  or  of  colloid 
substance  in  the  tumor  alters  the  consistency  markedly,  so  that 
it  is  impossible  to  recognize  the  true  nature  of  the  growth  simply 
by  physical  examination. 

Cancer  Period. — The  age  of  cancer  patients  is  usually  more  than 
thirty  years,  a  fact  that  only  emphasizes  the  need  of  great  caution 
KM  1 1 10- e  which  develop  in  younger  individuals  escape  unrecog- 
nized. The  different  types  of  cancer  and  those  occurring  in  certain 
-tructures  are  more  frequent  at  certain  periods  of  life.  For  in- 
stance, cancer  of  the  skin  occurs  more  frequently  after  the  age 
of  forty-five  years;  carcinoma  of  the  breast  is  seen  in  women  usually 
between  the  ages  of  thirty  and  sixty  years;  it  rarely  occurs  later 
than  this  age,  and  is  only  very  occasionally  observed  in  women 
between  twenty  ami  thirty,  very  seldom  in  girls  under  twenty. 
( 'ancer  of  the  stomach  is  more  common  between  the  ages  of  fifty 
and  seventy  years,  and  is  very  rare  before  the  age  of  thirty. 
(  'ancer  of  the  liver  occurs  at  the  average  of  51.0  year-  in  males  and 
117  years  in  females,  if  only  those  cases  are  considered  which 
occur  after  the  fifteenth  year  of  age  (Rolleston).  A  large  propor- 
tion of  case-  of  cancer  of  the  liver  in  adults  develop  in  cirrhotie 
livers.  This  is  not  true  of  hepatic  cancer  in  the  young.  The 
above  illustration-  only  serve  to  impress  that  once  an  individual 
ha-  passed  the  cancer  aire  the  recognition  of  the  nature  of  the 
trouble  must  depend  almo-t  if  not  altogether  on  other  evidence 
than  the  decade  of  life.  This  is  true  in  a  more  limited  way  of 
those  who  have  not  reached  the  a^e  of  thirty  years. 

Cancer  occurs  very  rarely  in  the  young;  it  is  by  no  means 
limited  to  individual-  beyond  the  aj:e  of  thirty  or  even  twenty 
yean.  The  distribution  of  cancer  in  children  is  limited  to  a  very 


600  PRINCIPLES   OF   SURGERY 

few  organs,  being  confined  chiefly  to  the  liver,  alimentary  tract, 
uterus,  ovary,  and  skin.  It  may  occur  even  during  the  first  few 
months  of  life.  It  must,  however,  be  emphasized  again  that  cancer 
in  the  young  is  one  of  the  very  rare  pathologic  conditions. 

Pain. — Pain  in  cancer,  as  in  sarcoma,  has  been  given,  unfor- 
tunately, too  great  value  as  a  symptom.  It  may  be  stated  cor- 
rectly either  that  pain  is  or  is  not  a  symptom  of  cancer.  The  rule  is 
that  cancer  is  painless  at  the  beginning,  and  it  often  remains  free 
from  pain  until  long  after  the  tumor  has  reached  the  inoperable 
stage.  If  this  symptom  be  waited  for  to  confirm  the  diagnosis, 
cancer  statistics  would  appear  much  more  hopeless  than  at  present. 
When  one  considers  how  a  cancer  may  produce  pain,  it  becomes 
self-evident  that  pain  would  not  usually  appear  as  an  early  symp- 
tom. Pam  is  produced  by  the  mechanical  interference  with 
function,  as  in  the  cases  of  stricture  and  obstruction  of  hollow 
viscera,  by  the  interference  with  normal  motility,  as  hi  case  of 
infiltration  of  the  bladder  or  rectum;  by  the  presence  of  a  pre- 
vious condition  on  which  the  cancer  has  built  and  which  of  itself 
is 'painful,  as  in  those  cancers  which  develop  on  painful  ulcers  of 
the  stomach;  by  infiltration  or  by  compression  of  sensory  nerve- 
fibers;  and  by  such  complications  as  ulceration  and  inflammation. 
These  are  either  rare  or  late  conditions,  and  it  must  follow  that 
cancer  is  not  painful  in  its  early  stages,  when  treatment  offers 
most  to  the  patient.  This  is  borne  out  almost  universally  by  the 
clinical  history  of  the  cases.  But  as  the  tumor  advances,  infil- 
trates, ulcerates,  attacks  other  organs,  metastasizes,  becomes 
inflamed,  or  causes  a  narrowing  of  the  lumina  of  hollow  structures, 
pain  may  be  not  only  present,  but  unbearable  and  unrelievable. 

Encapsulation. — I  have  said  already  that  cancer  is  a  non- 
capsulated  tumor.  The  only  exception  to  this  is  hi  those  cases 
where  malignant  cells  have  developed  in  a  growth  that  is  already 
encapsulated  and  have  not  yet  had  time  to  penetrate  the  limiting 
sheath.  It  grows  habitually  by  infiltration  and  confines  itself 
within  no  anatomic  limits.  Hence,  there  are  two  clinical  signs  of 
great  importance:  first,  that  cancer  is  not  a  movable  tumor,  or, 
what  amounts  to  the  same  thing,  namely,  that  when  it  invades  a 
structure,  that  structure,  as,  for  example,  the  mucous  membrane 
of  the  rectum,  no  longer  can  be  glided  over  the  submucosa  when  it 
has  been  infiltrated  by  cancer  of  the  uterus,  bladder,  or  prostate. 
So,  too,  of  the  mucous  membrane  of  the  mouth  or  stomach.  The 
second  sign,  dependent  upon  infiltration  and  absence  of  a  capsule, 
is  the  indefiniteness  of  the  edges  of  the  tumor,  so  that  one  cannot 
determine  by  palpation  just  where  tumor  tissue  leaves  off.  But 
the  growth  of  cancer  by  direct  extension  may  reach  far  and  wide 
beyond  any  clinically  expected  limit,  as  is  shown  by  the  cases  of 


CANCER  601 

invasion  of  the  upper  abdomen  by  cancer  of  the  breast  when  all 
I x -tween  the  two  growths  is  apparently  normal;  or  by  the  affection 
of  lymph-nodes  by  root-like  processes  growing  along  the  lumen  of 
the  lymph-channels. 

Shape. — The  shape  of  cancer  is,  like  some  of  its  other  charac- 
teristics, very  variable.  It  may  grow  as  a  distinctly  round,  smooth 
tumor.  This  is  exceptional,  especially  in  the  later  stages.  It 
may  grow  as  a  flat  tumor,  covering  wide  surface  areas  and  refusing 
to  invade  the  deeper  structures  extensively,  as  is  shown  by  the 
flat  epitheliomata  of  the  skin;  it  grows  often  as  a  nodular  mass, 
as  is  illustrated  by  nodular  carcinoma  of  the  liver;  or,  again,  the 
tumor  may  be  very  irregular  in  outline,  apparently  growing  in 
certain  directions  more  readily  than  in  others,  or  if  scirrhus,  by  its 
contraction  and  destruction  of  tissue,  accomplish  the  same  result. 

Consistency. — The  consistency  of  cancer  is  just  as  variable  as 
its  shape.  The  slow-growing  tumors  are  hard  directly  in  pro- 
portion to  the  density  of  their  tissue;  the  cellular  tumors  are  soft 
or  encephaloid.  Besides  this,  the  tumor  may  be  either  cystic 
or  colloid,  and  thus  become  distinctly  fluctuant  uniformly  or  in 
spots. 

Lymphatic  Invasion. — Lymph-node  involvement  is  one  of  the 
important  diagnostic  signs  of  cancer,  although  it  must  be  looked 
upon  as  a  relatively  late  sign,  for  enlargement  of  a  node  or  group 
of  nodes  means  that  the  tumor  has  reached  that  far  at  least. 
Alienee  of  perceptible  lymph-node  enlargement  does  not  mean 
that  the  node  is  not  yet  invaded;  it  is  only  presumptive  evidence. 
It  must  not  be  concluded  that  every  case  of  lymph-node  enlarge- 
ment in  connection  with  a  cancer  indicates  that  they  are  cancerous; 
they  may  have  been  present  from  other  causes  and  prior  to  its 
origin;  they  may,  on  the  other  hand,  be  subsequent  to  the  origin 
of  the  cancer  and  still  not  due  to  cancerous  invasion,  but  to  an  in- 
fection gaining  entrance  through  an  ulcer  on  the  cancer.  In  case 
of  doubt,  it  is  better  to  assume  that  they  are  cancerous  or  to  sub- 
ject one  or  more  of  them  to  the  microscope.  The  presence  of 
adherent  lymph-nodes  would  indicate  that  the  capsules  of  the 
nodes  had  been  infiltrated  and  that  they  were  thereby  attached 
to  the  surrounding  structures.  Lymph-node  involvement  may 
occur  in  several  directions  at  once,  and  it  does  not  necessarily 
follow  the  direction  of  the  lymph-stream.  Hence  a  thorough 
exci>ion  may  completely  eradicate  the  cancerous  cells  from  one 
region,  and  failure  or  impossibility  to  do  so  in  another  determines 
the  recurrrnce  of  the  tumor.  There  is  no  limit  to  the  number  of 
Kmph-nodi-  in  a  chain  which  may  be  invaded,  for  the  growth 
extends  from  one  to  another  indefinitely.  For  example,  the 
entiiv  tenet  from  clavicle  to  pelvis  may  be  invaded  from  a  pelvic 


602 


PRINCIPLES   OF   SURGERY 


cancer.     It  has  been  shown  already  that  lymph-nodes  may  be 
invaded  either  by  direct  growth  or  by  lymphatic  emboli. 

Metastasis. — Metastasis  occurs  either  by  distribution  of  cancer 
cells  in  the  form  of  emboli  through  the  lymphatics  or  the  blood. 
The  former  has  been  sufficiently  discussed  under  Lymph-node 
Involvement.  Cancer  cells  gain  entrance  to  the  blood  by  invasion 
of  the  vessels,  especially  the  veins,  and  possibly  sometimes  through 
the  lymphatic  trunks  which  pour  their  contents  into  the  veins  in 
the  upper  thorax.  The  distribution  of  metastases  is  accidental  or 


Fig.  205. — General  skeletal  metastases  secondary  to  cancer  of  the  breast. 

selective.  By  the  former  term  is  meant  that  the  metastasis  de- 
velops where  the  embolus  lodges,  if  the  circumstances  at  that 
point  are  favorable  to  the  growth  of  the  cells;  it  is  probable  that 
large  numbers  of  cancer  emboli  never  grow  after  their  lodgment. 
If  the  primary  cancer  is  in  the  region  whose  veins  empty  into  the 
portal  vein,  the  majority  of  the  metastases  will  appear  in  the 
liver;  if  they  gain  entrance  through  the  veins  of  the  general  cir- 
culation, the  emboli  are  more  likely  to  lodge  in  the  capillaries  of 
the  lungs.  Hence  it  happens  that  the  lungs  and  the  liver  are  so 
frequently  affected  by  secondary  cancer.  If  the  foramen  ovale  is 


CANCER  603 

patent,  as  it  is  in  a  large  percentage  of  cases,  the  lungs  may  escape 
and  a  -o-ca lied  crossed,  or  paradoxic,  embolism  may  occur.  The  site 
of  lodirment.  /.  e.,  whether  in  capillaries  or  arteries,  depends,  as  in 
other  cases  of  embolism,  on  the  size  of  the  embolus.  It  is  self- 
evident  that  death  in  these  cases  may  result  suddenly  fromem- 
l>oli>m.  Smaller  eml>oli  may  escape  the  capillaries  of  liver  or 
lung  .and  lodge  in  peripheral  portions.  By  the  term  selective 
metastasis  is  meant  the  tendency  certain  tumors  show  to  produce 
metastases  only  in  certain  tissues  or  organs,  aside  from  the  acci- 
dent of  relative  position  in  regard  to  the  circulation.  As  the  most 
notaMe  illustration  may  be  mentioned  the  frequency  with  which 
the  osseous  system  is  invaded  by  metastases  in  cases  of  cancer  of 
the  breast  or  of  the  prostate;  skeletal  metastases  are  more  common 
hi  women.  The  bone  may  show  simply  a  majority  of  the  metas- 
tases, or  they  may  be  found  only  in  the  bones,  if  we  exclude  inva- 
-ion  of  the  lymph-nodes.  Metastasis  of  the  skeleton  occurs  with 
considerable  frequency  in  cancer  of  the  stomach,  less  often  from 
cancer  of  the  gall-bladder,  uterus,  intestines,  esophagus,  and  skin. 
The  l>ones  most  frequently  attacked  are  the  pelvic  bones,  the  ster- 
num, the  spinal  column,  the  femur,  but  the  whole  skeleton  may  be 
invaded,  producing  a  condition  which  has  been  termed  carcinoma- 
tou-  oeteamalacia,  in  which  the  most  bizarre  and  extensive  de- 
formities of  the  skeleton  occur.  On  the  other  hand,  spontaneous 
tract ui r.  practically  painless  or  much  less  painful  than  traumatic 
fracture,  may  be  the  first  evidence  that  metastasis  has  occurred, 
or  even  the  first  evidence  of  the  presence  of  cancer.  Metastases  of 
t  he  lung  are  especially  frequent  in  cancer  of  the  stomach  and  of  the 
thyroid  gland.  This  is,  however,  probably  accidental  and  due  to 

iective    influence. 

The  time  intervening  between  the  escape  of  an  embolus  and  its 
formation  into  a  distinct  tumor  is  very  variable.  It  may  occur 
in  a  short  time  under  favorable  circumstances,  or  where  the  in- 
hibitive  action  is  marked  the  metastasis  may  lie  quiescent  for 
yean;  the  time  limit,  as  usually  accepted,  is  three  years,  but 
numerous  cases  of  remote  metastatic  recurrence .  have  been  ob- 
served. Then-fore  the  period  during  which  metastases  may  lie 
<iuie>c(  nt  is  the  measure  of  the  time  one  must  wait  before  pro- 
nouncing a  cure. 

There  i>  no  uniformity  in  the  l>ehavior  of  cancer  relative  to 
meta.-ta-.-  through  the  Mood.  In  one  instance  the  tumor  may  be 
large  and  of  long  duration  and  produce  no  metastases,  while 
another  of  recent  origin  or  very  small,  possibly  undiscoverable, 
may  invade  the  entire  body,  the  metastases  first  calling  attention 
to  the  presence  of  a  pathologic  condition. 

A  type  of  meia-taHs  or.  more  probably,  a  plan  of  growth  some- 


604  PRINCIPLES   OF   SURGERY 

times  observed  is  the  separation  of  cancer  cells  from  their  fellows 
and  their  dispersion  short  distances  from  the  primary  tumor  into 
the  surrounding  connective  tissue,  where  they  set  to  multiplying 
and  produce  new  nodules.  This  is  to  be  distinguished  from  those 
cases  which  grow  diffusely  through  the  lymph-channels  and  de- 
velop numerous  nodules  along  their  course,  as  is  seen  sometimes 
in  cancer  of  the  pleura. 

The  escape  of  cancer  cells  into  a  large  serous  cavity,  notably 
the  peritoneum,  causes  metastases  on  the  membranous  lining. 
The  cells  are  distributed  over  the  surface  by  the  motion  of  its 
contents  and  become  engrafted  and  grow.  The  tumors  may  be 
so  small  and  numerous  and  so  closely  resemble  tubercles  as  to  lead 
the  surgeon  to  give  a  diagnosis  of  tubercular  peritonitis.  The  nor- 
mal erect  position  of  the  body  causes  the  cells  to  settle  in  the  culde- 
sac  of  Douglas,  and  this  is  the  most  frequent  site  of  secondary 
cancer  of  the  peritoneum.  The  next  point  of  frequency  is  the 
furrow  along  the  line  of  attachment  of  the  mesentery  to  the  gut, 
a  position  which,  once  attained  by  the  cancer  cells,  fairly  well 
secures  them  against  displacement.  As  the  individual  masses  grow 
they  coalesce  and  ultimately  so  shorten  the  mesentery  as  to  draw 
the  alimentary  tract  close  down  to  the  line  of  mesenteric  attach- 
ment to  the  posterior  abdominal  wall.  Peritoneal  cancer  is  ac- 
companied by  ascites,  which  is  often  bloody. 

When  cancerous  metastases  occur  in  great  numbers  they  may 
be  exceedingly  small  and  widely  distributed  throughout  the  organs 
of  the  body  and  rapidly  result  in  death.  The  condition  is  termed 
general  cardnomatosis. 

Implantation  carcinoma  is  a  secondary  form  in  which  cancer 
has  become  implanted  upon  a  new  site  by  contact  and  the  deposit 
of  some  of  its  cells,  which  have  taken  and  grown  as  a  graft.  The 
practical  importance  of  this  possibility  cannot  be  overestimated. 
He  who,  while  operating  for  cancer,  cuts  or  tears  into  the  tumor 
substance  and  thus  allows  tumor  cells  to  be  displaced  into  the 
wound  stands  in  great  danger  of  seeing  an  implantation  recur- 
rence. The  same  thing  .may  happen  in  removal  of  a  visceral 
cancer  which  is  allowed  to  touch  the  wound  edges;  a  case  of 
Kelly's  showed  recurrence  in  the  cicatrix,  although  the  pelvis 
from  which  a  cancerous  uterus  was  removed  remained  free.  In 
aspirating  for  cancerous  ascites  cancer  cells  may  be  lodged  hi  the 
track  made  by  the  needle  and  develop  into  a  secondary  tumor. 

It  has  been  stated  already  that  cancer  cells  grow  either  in  their 
primary  or  secondary  position  with  very  variable  readiness.  As 
the  patient  becomes  more  poisoned  by  the  presence  in  his  body  of 
a  cancer,  by  anemia,  by  hemorrhage,  ulceration,  or  infection,  as, 
in  a  word,  cachexia  develops,  the  tumor  cells  meet  with  less  re- 


CANCER  605 

sistance  on  the  part  of  the  tissues  and  the  tumors  grow  much 
more  readily. 

Degeneration. — Degeneration  of  cancer  tissue,  whether  of  the 
parenchyma,  stroma,  or  both,  is  a  very  common  occurrence.  It 
is  almost  universal  in  those  tumors  that  have  reached  a  relatively 
large  size,  and  is  due,  as  has  been  explained  already,  to  the  in- 
sufficient circulation  of  blood  in  the  central,  older  portions  of  the 
tumor.  Two  important  facts  have  their  foundation  on  this 
tendency  to  degeneration:  one  is  that  the  tumor  grows  only  from 
its  living  undegenerated  peripheral  cells  and  that  specimens  for 
microscopic  examinations  should  be  chosen  from  an  outer  zone; 
the  second  is  the  tendency  for  cancers  to  ulcerate  and  be  ex- 
ten -ively  destroyed  by  this  process.  A  third,  of  minor  importance, 
may  be  mentioned,  namely,  the  change  produced  in  the  con- 
ucy  of  the  tumors  by  degenerative  action. 

Ulceration. — Ulceration  is  a  very  frequent  complication  of 
cancer,  on  which  frequently  depends  the  very  first  evidence 
that  the  tumor  is  present.  This  is  so  emphatically  true  that  in 
concealed  cancers  of  the  mucous  membrane  the  discharges  from 
an  ulcerative  surface  are  uniformly  sought  for  as  clinical  evi- 
dence. This  is  especially  true  of  cancer  of  the  stomach  and  of  the 
bladder.  When  the  tumor  is  situated  superficially  or  when  by 
infiltration  it  ultimately  invades  skin  or  mucous  membrane,  ul- 
ceration is  very  likely  to  occur.  It  does  not  occur  in  cancers  of  the 
deeper  structures  unless  the  tumor  has  been  inadvertently  incised 
by  the  physician.  Then,  of  course,  if  it  is  rapidly  growing,  it  im- 
mediately pushes  its  way  through  the  incision  and  forms  a  fungoid 
ma— .  When  ulceration  begins  in  a  cancerous  mass  it  continues 
Indefinitely;  the  ulcer  may  be  covered  with  decomposed  tissue  or 
may  suppurate  more  or  less  extensively,  or  its  surface  may  be 
rather  clean,  showing  the  red,  raw,  growing  mass  of  cells.  In  the 
majority  there  is  no  tendency  for  epithelium  to  build  over  this 
surface,  although  this  does  occasionally  happen  imperfectly  in 
some  of  the  more  slowly  growing  tumors,  such  as  Paget's  disease 
of  the  nipple.  The  ulcerative  process  may  almost  keep  pace  with 
the  rate  of  growth  of  the  tumor,  so  that  there  is  only  a  small  zone 
of  cancer  cells  surrounding  it,  as  is  seen  in  rodent  ulcer,  or  it  may 
invade  it  imperfectly,  so  that  in  spite  of  prolonged  ulceration  a 
considerable  tumor  mass  remains.  The  central  ulcerative  area 
is  soi  in  'tin  icv  MM- rounded  by  several  smaller  ones. 

Hi-morrhayr.—  lii  conx-<]iience  of  the  ulrrration  of  cancer 
several  other  important  -ymptoms  develop,  namely,  hemorrhage, 
ex-ape  of  serum,  infection,  necrosis,  and  -tench,  all  of  which  play 
an  important  r61e  either  directly  or  indirectly  in  the  local  and 
general  symptomatology  of  cancer. 


606  PRINCIPLES   OF   SURGERY 

Necessarily,  hemorrhage  is  to  be  considered  in  any  case  of 
ulcerative  cancer.  It  plays  a  much  less  important  part  in  non- 
ulcerative  cancer  than  it  does  in  sarcoma.  The  hemorrhage  varies 
with  the  site  of  the  cancer,  the  nature  of  the  growth,  and  the  source 
of  hemorrhage,  i.  e.,  whether  it  comes  from  the  vessels  of  the 
cancer  itself  or  from  some  important  vessel  that  has  been  at- 
tacked. Surface  cancers  that  are  ulcerated,  of  course,  bleed 
somewhat,  but  it  is  unusual  to  see  dangerous  hemorrhage  from 
them,  partially  owing  to  the  fact  that  they  are  usually  superficial 
to  the  amount  of  connective  tissue  they  contain,  and  to  the  ease 
of  recognition  and  the  accessibility  to  treatment;  cancer  of  the 
stomach,  the  uterus,  and  the  bladder  are  very  prone  to  bleed,  and 
hi  these  organs  the  suspicion  of  the  patient  is  first  aroused  and  the 
clinical  picture  frequently  made  clear  to  the  physician  only  by  the 
presence  of  hemorrhage.  Hence  the  necessity  of  examining  the 
stomach  contents  or  feces  in  suspected  cases  of  gastric  cancer. 
It  is  necessary  to  exclude  all  hemoglobin  contained  hi  the  food 
from  the  alimentary  tract  before  the  finding  of  minute  quantities  of 
blood  can  be  relied  on.  So,  too,  the  urine  is  examined  for  blood 
in  suspected  cancer  of  the  bladder.  It  cannot  be  too  emphatically 
stated,  however,  that  negative  findings  in  any  instance  are  not  to 
be  accepted  as  an  assurance  that  cancer  is  not  present.  Likewise 
the  presence  of  blood  may  be  attributed  to  many  other  causes  than 
cancer.  Hemorrhage  is  only  one  of  the  possible  signs  of  cancer. 
Aside  from  its  diagnostic  importance,  hemorrhage  may  become 
an  urgent  and  uncontrollable  complication,  being  ojie  of  the  most 
frequent  causes  of  death  in  cancer,  or  it  may  by  the  slow  loss  of 
small  quantities  of  blood  gradually  exhaust  the  strength  of  the 
patient  and  add  to  the  cachexia  so  often  seen  in  advanced  cases. 
The  hemorrhage  may  come  from  numerous  oozing  points  and  be 
caused  by  the  slightest  manipulation  or  by  some  effort  of  the 
patient,  but  independently  of  all  extraneous  causes  they  bleed 
of  their  own  accord;  again,  the  hemorrhage  may  be  profuse 
and  from  one  or  more  larger  vessels  of  the  cancerous  mass  or  of 
the  region  hi  which  it  rests. 

The  same  influence  produced  by  slow  hemorrhage  may  be 
produced  also  by  the  continued  leakage  of  body  fluids  from  the 
ulcerative  surface  with  little  or  no  attendant  hemorrhage. 

Infection. — Infection  is  another  complication  arising  early 
after  the  advent  of  ulceration.  Both  pathogenic  and  saprophytic 
bacteria  may  enter,  and  the  dead,  degenerated  tissues  of  the  tumor 
offer  them,  especially  the  saprophytes,  an  excellent  field  for  de- 
velopment. Inflammation  and  suppuration  may,  therefore,  appear 
as  a  complication  of  cancer,  but  the  saprophytic  bacteria  are  re- 
sponsible for  the  more  characteristic  decomposition  and  stench, 


CANCER  607 

which  is  often  so  intense  as  to  be  unbearable,  working  the  greatest 
hardship  on  both  patient  and  attendants.  The  obnoxious  effect 
of  the  malodor  of  cancer,  especially  cancer  of  the  uterus,  cannot 
t.r  r\au Derated. 

Cachexia. — Cachexia  is  a  reliable  general  symptom  of  cancer, 
but  when  it  appears  sufficiently  marked  to  be  of  great  value  the 
case  is  usually  advanced  beyond  the  hope  of  recovery.  It  i>, 
therefore,  not  to  be  waited  for;  it  would  be  indeed  fortunate  if  the 
symptom  could  forever  pass  from  the  literature  of  malignant 
tumors.  Cachexia  does  not  show  early;  it  may  even  not  appear 
until  a  few  weeks  or  months  before  death.  There  can  be  no  doubt 
that  eachexia  may  be  produced  by  cancer  pure  and  simple.  Like- 
wi-e  there  is  no  doubt  in  the  minds  of  those  who  study  the  clinical 
murse  of  large  numbers  of  cases  that  it  is  very  often  largely  at- 
tributable to  accidents  or  complications.  Hence  it  is  that  the 
patient  may  continue  in  fair  general  health,  weight,  and  appearance 
for  a  long  period  of  time,  and  then  suddenly  develop  cachexia  in  the 
course  of  a  few  weeks.  Hemorrhage,  whether  continuous  and 
slight,  or  large  and  repeated,  the  loss  of  body  fluids  in  the  form  of 
serum  or  pus,  the  deleterious  effect  of  ptomains  and  toxins  from  an 
ulcerated  surface,  and  the  interference  with  normal  vital  functions 
are  t  he  common  factors  aiding  in  the  causation  of  cachexia.  Hence 
the  patient  who  has  cancer  of  the  mouth,  esophagus,  or  upper  in- 
te-tine  starves,  and  the  one  who  has  cancer  of  the  rectum  is 
cachectic,  partially  because  he  cannot  secure  proper  motions  and 
Mies  auto-intoxicated  from  retained  feces.  So,  too,  the  pros- 
tat  ic  and  bladder  cancers  interfere  with  general  nutrition  by 
retention  of  urine  and  by  the  encouragement  offered  to  infection 
of  the  bladder  and  kidneys.  It  is  of  great  prognostic  importance  to 
be  aide  to  say  whether  the  cachexia  present  in  a  case  of  cancer  is 
due  chiefly  to  the  cancer  or  to  some  incidental  occurrence,  for  in 
the  latter  instance  it  is  often  possible  to  eliminate  the  cause, 
build  up  the  general  condition  of  the  patient,  and  relieve  him  by  a 
satisfactory  surgical  procedure,  while  in  the  former  such  a  course 

will   rarely   he   feasible. 

l-'trer. — The  temperature  is  usually  undisturbed  by  the  pres- 
ence of  cancer  except  in  those  cases,  of  course,  where  complica- 
tions  arise  which,  independently  of  the  tumor,  produce  fever. 
There  are  exceptions,  however,  as  carcinoma  may  cause  a  moder- 
ate febrile  reaction  occasionally.  Thi-  i<  e-pecially  true  of  general 
carcinoma!  i. -i-.  The  fever  may  be  continuous  and  must  be  differ- 
entiated especially  from  malaria  and  sepsis. 

A  HI  win.  The  Mood  changes  of  cancer  are  important,  though 
not  characteristic.  The  anemia  may  assume  a  mild  chlorotic  form 
or  be  a  facsimile  of  pernicious  anemia,  the  former  in  the  acute, 


608  PRINCIPLES   OF   SURGERY 

rapidly  growing,  metastasizing  growths,  the  latter  in  the  slow- 
growing,  chronic  forms,  among  which  latent  cancer  must  not  be 
forgotten.  This  is  paradoxic,  but  largely  borne  out  by  clinical 
findings.  The  anemia  of  cancer  may  be  said  to  go  hand  in  hand 
with  cachexia  and  to  be,  indeed,  a  part  of  it.  The  same  causes 
which,  hi  addition  to  the  presence  of  malignant  tumor,  intensify 
the  cachexia,  increase  the  anemia.  Thus  hemorrhage,  wasting  of 
body  fluids,  interference  with  correct  elimination,  and  the  ab- 
sorption of  poisonous  products  are  responsible  for  both  conditions. 
The  red  cells  may  be  reduced  to  2,500,000  or  even  as  few  as 
1,000,000.  The  white  cells  may  be  relatively  or  absolutely  in- 
creased. Leukocytosis,  when  present,  is  usually  due  to  a  larger 
percentage  of  polymorphonuclears,  but  there  are  exceptions,. 
Leukocytosis  is  more  often  present  hi  rapidly  growing  tumors. 
"Myelocytes  are  perhaps  more  frequently  found  hi  cancer  than 
in  the  other  types  of  anemia,  excepting  pernicious  anemia  and 
leukemia"  (Webster). 

Multiple  Primary  Growths. — Cancer  usually  dccurs  as  a  single 
primary  growth,  although  there  are  numerous  cases  recorded  hi 
which  there  were  primarily  two,  sometimes  several,  growths, 
occurring  at  or  about  the  same  time  and,  without  question,  inde- 
pendent of  each  other.  Or  they  may  appear  successively  at  vary- 
ing intervals  and  affecting  the  same  structure  or  widely  separated 
structures.  They  may  occur  hi  a  given  tissue  and  be  close  to- 
gether and  due  to  the  same  apparent  cause,  or  widely  apart  and 
from,  so  far  as  we  know,  entirely  different  causes.  The  most 
frequent  site  of  multiple  primary  cancer  is  the  skin. 

Cutaneous  Reaction. — The  diagnosis  of  cancer  by  the  attempt 
to  elicit  cutaneous  reactions  has  recently  been  the  subject  of 
extensive  research,  but  is  not  established  with  sufficient  accuracy 
to  demand  a  discussion  in  this  text. 

Special  Symptoms  of  Cancer  in  Various  Organs. — The  symp- 
toms and  signs  of  cancer  discussed  above  are  dependent  upon  the 
presence  of  cancer  and  the  accidents  and  complications  that  may 
befall  it  in  a  general  way.  There  are,  hi  addition  to  these,  other 
special  signs  and  symptoms  of  varying  importance  attaching  to 
cancer  of  various  organs  and  often  of  the  utmost  diagnostic  value, 
especially  where  the  cancer  is  so  concealed  as  to  be  inaccessible  to 
the  usual  means  of  examination,  and  where  the  more  apparent 
symptomatology  might  arise  from  other  causes  than  cancer.  It 
is  necessary  to  discuss  briefly  the  more  important  special  facts  hi 
connection  with  cancer  of  the  various  organs,  especially  those  more 
frequently  attacked. 

Breast. — Cancer  of  the  breast  arises  usually,  except  in  Paget's 
disease  of  the  nipple,  as  a  single  nodule  situated  in  the  breast  more 


CANCER  609 

or  less  widely  separated  from  the  nipple  and  more  frequently 
(58  per  cent.)  in  the  upper  outer  quadrant  than  in  any  other. 
About  18  per  cent,  in  the  lower  inner  quadrant  and  the  rest  near 
tin  center.  The  tumor  grows  with  varying  rapidity  and  may  reach 
an  enormous  size  if  left  untreated.  As  growth  continues  the  nipple 
begins  to  retract  and  may  be  completely  submerged  below  the 
surrounding  level  of  the  skin.  Retracted  nipples  are  not  to  be  taken 
as  diagnostic,  for  the  condition  may  be  present,  either  unilateral 
or  bilateral,  in  healthy  breasts.  Before  the  retraction  is  apparent 
one  may,  by  drawing  the  nipple  away  from  the  tumor,  feel  a  cord- 
like  band  leading  from  the  nipple  to  the  tumor,  and  this,  when 
present,  is  very  significant.  This  is  known  as  Halsted's  sign. 
As  growth  continues  the  skin  may  be  invaded,  becoming  thick- 
ened in  appearance,  immovable  over  the  subcutaneous  tissues  and 
more  or  less  corrugated  like  orange  peel,  especially  if  an  attempt  is 
made  to  pinch  it  up.  The  skin  may  be  reddened  when  it  is  invaded. 
The  infiltration  mats  the  structures  of  the  breast  together  into  a 
conglomerate  mass  and  attaches  the  breast  to  the  pectoral  fascia, 
pectoral  muscles,  ribs,  pleura,  and  even  lung.  The  nodes  com- 
monly and  usually  rather  early  involved  are  the  subpectoral  nodes 
and  the  axillary  nodes.  The  supraclavicular  nodes  are  not  infre- 
quently invaded,  usually  a  later  occurrence  than  axillary  involve- 
ment. Sometimes  the  opposite  breast  is  invaded,  and  rarely  the 
axillary  lymph-nodes  of  the  opposite  side  of  the  body.  Less 
frequently  than  the  axillary  nodes  the  mediasthial  nodes  are 
attacked,  a  fact  that  should  always  be  borne  in  mind  as  rendering 
the  prognosis  hopeless,  and  adding  a  bit  of  uncertainty  in  every 
case,  as  they  are  usually  discoverable  by  no  clinical  method. 
Both  breasts  are  invaded  in  between  6  and  7  per  cent,  of  the  cases; 
thi>  includes  multiple  primary  tumors  and  secondary  extension. 
The  presence  of  cancer  in  the  prolongation  of  the  breast  toward 
the  axilla,  which  may  have  no  apparent  connection  with  the 
breast,  and  in  accessory  mammary  tissue  is  very  likely  to  be  mis- 
leading. They  deserve  to  be  dealt  with  just  as  any  other  breast 
eaneer.  Cancer,  of  course,  may  occur  in  supernumerary  breasts. 
As  an  illustration  of  the  possil»ilities  of  cancerous  growth  along 
the  lymph-channels  I  quote  the  following  from  Kaufmann's 
Spezidlt  r<itli<>h><iisrlte  Anatomic:  "Gerota  showed  exactly  the 
collateral  and  retrograde  routes  which  the  lymph  follows  after 
extirpation  of  the  l>rea-t.  namely,  to  the  other  breast,  into  the 
mediastinum,  and  even  as  far  down  as  the  inguinal  region.  The 
author  saw  exactly  this  mode  of  >pn-ad  in  a  case  of  inoperable 
carcinoma  in  a  woman  of  seventy,  which  hejran  in  the  ri^ht  breast, 
then  went  to  the  left  breast,  occupied  lioth  axillae,  infiltrated  the 
cervical  lymph-nodes,  penetrated  the  mediastinum,  and  extended 

39 


610  PRINCIPLES   OF   SURGERY 

downward  below  the  breast  in  the  form  of  nodular  cords  on  both 
sides  in  the  skin  and  beneath  it  over  the  abdomen  to  the  greatly 
enlarged  inguinal  lymph-nodes.  There  were  numerous  metastases 
in  the  bones." 

As  the  growth  of  the  cancer  continues  the  muscles  allow  less  and 
less  use  of  the  arm,  and  when  the  axillary  vessels  are  compressed  or 
invaded  the  arm,  forearm,  and  hand  may  become  enormously 
swollen  and  useless  on  account  of  edema. 

Scirrhus. — Scirrhus  has  already  been  sufficiently  described. 
One  form  of  it  deserves  especial  mention,  namely,  the  so-called 
cancer  en  cuirasse.  Scirrhus  may  produce  an  infiltration  or  indura- 
tion of  the  skin,  which  extends  widely  over  the  thorax  or  may  even 
entirely  surround  it,  drawing  so  tightly  down  upon  the  thorax 
and  its  muscles  and  vessels  as  to  produce  marked  restriction  of 
movement,  impair  respiration,  and  cause  intense  edema  of  the 
upper  extremity.  The  condition  is  usually  preceded  by  a  discov- 
erable tumor  in  the  breast,  although  in  some  instances  the  tumor 
appears  afterward;  rarely  cancer  en  cuirasse  develops  after  an 
operation  for  scirrhus.  It  is  due  to  invasion  of  the  lymph-channels 
and  the  formation  of  connective  tissue  in  the  affected  region. 
The  skin  becomes  hard,  brawny,  leathery,  thickened,  often  pig- 
mented,  and  may  show  dilated  veins  over  its  surface.  At  the  be- 
ginning the  condition  is  manifested  by  the  development  of  reddish 
spots  in  the  region  of  the  breasts;  gradually  these  spots  become 
thickened  and  larger  and  may  have  a  nummular  shape.  Their 
size  varies  from  \  inch  in  diameter  down  to  the  size  of  a  mustard 
seed.  They  may  be  numerous  and  become  confluenct.  These 
nodules  may  be  inclined  at  times  to  be  in  groups.  Occasionally 
ulceration  is  observed  in  one  or  more  of  them. 

Colloid  cancer  of  the  breast  is  very  rare. 

The  metastases  of  cancer  of  the  breast  produced  by  emboli  in 
the  blood-vessels  are  more  frequent,  naturally,  in  the  soft  cancers, 
which  are  more  abundantly  found  in  young  women;  they  are  least 
frequent  in  the  scirrhous  forms.  The  pleura,  liver,  osseous  system, 
and  pelvic  organs  are  the  structures  more  commonly  invaded. 
The  stomach  may  rarely  be  invaded  secondarily  to  cancer  of  the 
breast.  This  may  be  due  to  embolism  or  to  extension  of  the 
growth  along  the  lymph-channels.  The  latter  is  probably  more 
likely' to  occur  in  scirrhus. 

Uterus. — Cancer  of  the  uterus  may  arise  either  in  the  cervix 
or  the  body,  and  may  be  epithelioma,  adenocarcinoma,  or  the 
papillary  type  (cauliflower).  Cancer  of  the  cervix  is  much  more 
common  than  cancer  of  the  body,  and  is  relatively  more  frequent 
in  women  who  have  borne  children;  they  are  also  more  commonly 
of  the  squamous-celled  type.  Cancer  of  the  uterus  may  occur 


CANCER 


611 


at  any  time  during  the  cancer  age,  but  it  is  more  common  in  women 
who  have  passed  the  menopause.  The  most  important  fact  to  be 
learned  on  this  subject  is  that  a  recurrence  of  the  flow  after  estab- 
lishment of  the  climacteric  is  usually  due  to  cancer.  If  it  is  neces- 
sary  to  investigate  menstrual  disturbances  prior  to  the  climacteric, 
it  i>  absolutely  imperative  to  spare  no  means  to  eliminate  cancer 
in  tlif  woman  who  "menstruates"  after  this  period. 

Infiltration  of  cervical  cancer  occurs  along  the  vagina  and  into 
the  bladder,  rectum,  body  of  the  uterus,  and  the  parametrial 
tissues.  The  peritoneum  may  be  secondarily  invaded,  sometime* 
in  the  shape  of  diffuse  peritoneal  carcinosis.  The  cervical  canal 


Fig.  206. — Cancer  of  the  cervix  uteri. 

may  be  stenosed,  establishing  a  pyometra.  The  ureters  may  \^e 
compressed,  causing  hydronephrosis.  When  the  bladder  and 
rectum  have  become  invaded,  interference  with  their  function 

may  be  marked  and  the  pain  and  distress  very  annoying.  As  the 
hemorrhoidal  veins  become  obstructed  hemorrhoids  develop  only 
to  add  to  the  distress.  Later,  fistula-  between  bladder  and  vagina 
or  between  rectum  and  vagina  may  form  and  add  their  quota 
to  the  already  intolerable  misery.  The  hypogastric  and  sacral 
lymph-nodes  are  the  first  to  be  involved  in  cervical  cancer,  later 
any  of  the  higher  groups  in  their  order  may  be  reached — iliac, 
lumbar,  portal,  bronchial,  (radical,  and  supraclavicular. 

Carcinoma  psamniosum  is  a  squamous-celled  cancer  or  adeiio- 


612  PRINCIPLES   OF   SURGERY 

carcinoma  of  the  uterus  in  which  concretions  have  been  formed. 
It  is  rare. 

Metastases  are  found  in  about  one-third  of  the  cases  of  cervical 
cancer,  and  are  found  more  frequently  in  the  liver  and  lungs. 

The  body  of  the  uterus  is  affected  by  cancer  only  about  one- 
tenth  as  frequently  as  the  cervix.  It  appears  usually  as  a  more  or 
less  nodular  growth,  but  sometimes  grows  rather  diffusely.  The 
uterus  is  usually  enlarged,  perhaps  to  the  size  of  a  cocoanut  or  a 
half-gallon  measure;  on  the  other  hand,  it  may  show  no  enlarge- 
ment. 

The  important  symptoms  of  the  advancing  growth  of  cancer 
of  the  uterus  are  pain,  discharge,  hemorrhage,  stench.  The  less 
they  are  perceptible,  the  more  fortunate,  for  at  its  best  the  history 
of  uterine  cancer  is  one  of  the  saddest  in  the  annals  of  surgery. 
This  is  so  true  that  every  case  of  the  least  suspicion  should  be 
subjected  frequently  to  thorough  examination. 

Stomach. — Cancer  of  the  stomach  is  very  frequent.  It  consti- 
tuted 28.66  per  cent,  of  all  of  Kaufmann's  cases  of  cancer  hi  Basle, 
and  37.22  per  cent,  of  all  his  cases  in  Gottingen.  Combined  statis- 
tics show  that  33  per  cent,  of  70,000  cancer  cases  were  gastric. 
They  are  the  cause  of  1  death  hi  every  75.  This  postmortem  find- 
ing is  a  sad  commentary  on  the  disproportionate  number  diag- 
nosed intra  vitam,  and  should  be  an  unqualified  stimulus  to  search 
along  more  fruitful  lines  for  the  real  cause  of  trouble  in  our  stomach 
cases.  Cancer  of  the  stomach  is  more  frequently  seen  between 
the  ages  of  fifty  and  seventy  years,  and  is  very  rarely  observed 
in  patients  younger  than  thirty  years.  It  is  found  in  men  more 
frequently  than  in  women,  about  65  to  70  per  cent,  being  in  the 
former.  The  more  acute  cases  of  gastric  cancer  run  a  very  rapid 
course,  terminating  in  death  in  six  or  eight  months;  the  chronic  or 
scirrhous  type  lasts  several  years.  The  average  duration  of  gastric 
cancer  is  about  two  years. 

Gastric  cancer  follows  upon  ulcer  of  the  stomach  in  more  than 
half  the  cases,  and  is  accordingly  more  commonly  located  at  or 
near  the  pylorus.  It  is  also  said  to  be  preceded  frequently  by 
gastric  catarrh,  especially  the  type  of  gastric  catarrh  caused  by 
drinking  alcohol.  Many  cases  originate  without  a  history  either 
of  catarrh  or  ulcer. 

The  most  important  facts  to  be  borne  in  mind  concerning  cancer 
of  the  stomach  are  that  there  is  no  means  of  making  a  correct 
clinical  diagnosis  while  the  cancer  is  in  an  operable  state;  that, 
therefore,  questionable  cases  should  be  subjected  at  the  earliest 
possible  time  to  exploratory  incision;  that  gastric  tests  and  clinical 
analyses,  except  when  they  show  blood,  are  very  unreliable  data, 
misleading  perhaps  as  often  as  they  are  correct,  or  even  oftener. 


CANCER  613 

The  important  symptoms  of  cancer  of  the  stomach  are  often 
wanting  and  the  patient  complains  only  of  "indigestion,"  which 
may  not  be  severe  enough  to  lead  him  to  consult  his  physician. 
The  presence  of  blood  in  the  stomach  contents  is  a  very  important 
symptom,  whether  it  be  shown  by  microscopic  examination,  by 
hematemesis,  or  melena;  severe  or  fatal  hemorrhage  is  compara- 
tively rare.  The  absence  of  hemorrhage  proves  nothing  except 
that  if  cancer  is  present  it  has  not  yet  reached  the  point  of  ulcera- 
tion.  The  appetite  is  lost  early  in  two-thirds  of  the  cases.  Flatu- 
lence is  a  very  common  early  symptom,  and  after  ulceration  and 
decomposition  begin,  the  eructed  gas  may  be  foul.  Pain  is  often 


Fin.  207. — Cancer  of  pyloric  end  of  stomach.     Cardiac  opening  at  right. 


the  first  symptom,  perhaps  in  one-third  the  cases,  or  there  may 
l>e  -imply  a  sense  of  discomfort  in  the  epigastrium  after  meals 
prior  to  the  onset  of  pain.  From  10  to  25  per  cent,  of  the  cases 

never  complain  of  pain.  When  pain  is  present  it  may  be  continu- 
ou-  or  periodic:  it  may  occur  after  meals  or  at  night;  there  is  no 

eharaeteristie  pain  in  gastric  cancer  either  as  relates  to  its  pres- 
ence, it-  time  of  occurrence,  it-  nature,  or  the  di.ue-tion  of  food. 
Kmaci.t'ion  i<  naturally  an  important  symptom,  and  often  is  the 
tir.-t  to  direct  attention  to  the  po-sil.ility  of  a  seriou-  lr-ion.  but 
it  may  occur  only  late.  A-  decomposition  ami  stagnation  of  the 
stomach  contents  occur,  vomiting,  inanition,  weakness,  and  all 
the  general  symptoms  follow.  It  i.-  here,  too,  that  characteristic 


614  PRINCIPLES   OF   SURGERY 

analyses  of  gastric  contents  are  to  be  found.  Symptoms  of  pyloric 
obstruction  may  be  so  marked  as  to  dominate  all  others.  Metas- 
tases  from  gastric  carcinoma  are  very  common  and  may  appear 
before  any  evidence  of  a  primary  growth  is  at  hand.  The  liver 
and  the  peritoneum  are  most  frequently  invaded;  the  lungs,  the 
kidneys,  the  ovaries,  and  the  osseous  system  are  also  rather 
frequently  invaded. 

Lymph-node  involvement  is  first  observed  usually  in  the  nodes 
at  the  smaller  curvature,  and  then  other  groups  of  nodes,  the 
subpyloric,  the  portal,  the  retroperitoneal,  the  mediastinal,  and 
the  supraclavicular  (4  per  cent.). 

Bladder. — Cancer  of  the  urinary  bladder  is  recognizable  only 
by  microscopic  examination,  as  it  cannot  be  distinguished  from 
papillomata  in  a  clinical  way.  Indeed,  many  of  the  so-called 
papillomata  of  the  bladder  are  to  be  considered  malignant  or 
certain  ultimately  to  become  malignant,  though  they  may  hot  be 
demons trably  so  at  the  time  of  examination.  The  passage  of 
blood  or  fragments  of  the  tumor  in  cancer  of  the  bladder  is  likely 
to  be  the  first  evidence  of  its  presence,  and  this  should  lead  to  a 
complete  cystoscopic  examination.  Tumors  of  the  bladder  are 
as  yet  not  understood  sufficiently  to  enable  one  to  discuss  them 
in  an  advantageous  way.  Some  that  show  benign  under  the 
microscope  recur  even  without  the  presence  of  clinical  evidence 
of  malignancy.  Some  authors  straddle  the  situation  by  calling 
the  questionable  cases  papillomatous  disease  of  the  bladder. 

Liver. — Carcinoma  of  the  liver  is  so  rare  as  a  primary  growth 
as  to  merit  but  little  discussion  here.  It  is  found  usually  in  the 
old,  but  occasionally  in  the  extremely  young,  even  down  to  the 
first  few  months  of  life.  It  is  exceedingly  frequent  as  a  secondary 
tumor,  being  found  in  26  per  cent,  of  all  cases  of  cancer  coming 
to  postmortem.  The  primary  growths  assume  various  forms :  first, 
the  massive  type,  which  may  appear  as  an  isolated  mass  or  be 
surrounded  by  a  group  of  secondary  nodules.  This  tumor  may 
attain  the  size  of  a  child's  head,  appear  nodulated  or  smooth,  and 
be  pseudofluctuant.  Second,  hi  cirrhotic  livers  the  tumor  may 
appear  as  a  diffuse  growth,  as  multiple  nodules,  or  a  combination 
of  the  two,  i.  €.,  an  infiltrative  nodular  form.  In  this  the  liver 
may  be  enormously  enlarged,  reaching  sometimes  the  weight  of 
more  than  20  pounds.  From  a  microscopic  standpoint  the  tumors 
are  of  the  alveolar  type,  the  cylinder-celled  type,  and  adeno- 
carcinoma,  the  latter  being  the  common  form  found  in  cirrhotic 
livers. 

The  secondary  growths  occurring  in  the  liver  are  sometimes 
umbilicated,  a  condition  rarely  observed  in  the  primary  forms. 

The  symptoms  of  cancer  of  the  liver  are  not  characteristic. 


CANCER  615 

The  first  sign  of  the  trouble  may  be  either  an  anemia  or  an  enlarge- 
ment of  the  girth.  This  increase  in  the  size  of  the  abdomen  is  due 
to  the  enlargement  of  the  liver  and  to  ascites,  if  the  latter  is  pres- 
ent. In  spite  of  the  emaciation,  the  size  of  the  tumor  and  the 
volume  of  ascitic  fluid  may  cause  an  increase  in  the  patient's 
weight  even  during  the  last  few  months  of  life.  Pain  is  present 
in  the  majority  of  cases  when  the  liver  capsule  is  distended  or  its 
peritoneal  coat  invaded.  There  are  exceptions  even  in  enor- 
mously distended  livers.  Tenderness  may  be  present,  and  is  more 
likely  if  the  peritoneum  is  affected.  Friction  fremitus  may  be  elic- 
it eil  in  the  latter  instance.  Fever  is  present  and  continuous  in 
a  goodly  number  of  cases,  explainable  on  no  other  grounds  than 
the  presence  of  the  tumor.  Jaundice  is  often  present,  but  not 
eon.-tant,  and  is  greenish  hi  contrast  to  the  yellow  jaundice  of 
eirrhosis;  it  may  be  replaced  by  a  sallow,  muddy  complexion. 
The  patients  are  extremely  weak.  Ascites  is  often  present,  but 
only  when  obstruction  is  sufficient  to  interfere  materially  with  the 
portal  circulation;  it  is  not  essential.  Hemorrhoids  and  edema  of 
the  feet  may  likewise  develop.  Metastases  occur  chiefly  in  the 
lungs  or  in  the  liver  itself,  the  former  from  entrance  of  tumor 
cells  into  the  hepatic  veins,  the  latter  from  their  entrance  into  the 
branches  of  the  portal  vein.  Lymphatic  invasion  is  rare. 

Cancer  of  the  gall-bladder  and  bile-ducts  was  found  hi  5  and  6 
JMT  cent,  respectively  of  the  cases  in  the  Basle  and  the  Gottingen 
laboratories.  They  are  nearly  always  sequent  upon  gall-stones, 
although  a  few  cases  are  found  in  which  no  gall-stones  are  present 
ami  which  have  no  history  of  symptoms  that  would  indicate  gall- 
stone disease.  The  tumors  originate  usually  about  the  neck  of 
the  gall-bladder,  but  the  fundus  may  be  the  site  of  origin.  The 
tumor  may  grow  diffusely  or  in  the  nodular  form.  The  gall- 
bladder is  frequently  distended  and  palpable,  the  contents  being 
pus  or  saniopurulent  fluid.  On  the  other  hand,  the  cancerous  gall- 
Madder  may  be  exceedingly  shriveled  and  small.  Secondary 
nodules  may  form  in  the  mucosa  of  the  common  duct  and  re-ult 
in  the  mo-t  intense  jaundice.  Jaundice  may  also  be  due  to  asso- 
ciated catarrhal  inflammation  of  the  bile-passages  or  to  stones. 
In  the  two  latter  in-taiic. •-  it  may  disappear  after  a  time,  but  when 
due  to  MocL-igr  of  the  ducts  by  the  tumor  it  is  continuous  and 
progre--ive.  Detention  of  the  gall-bladder  occurs  in  a  small 
percentage  (less  than  one-fourth)  of  the  obstructions  to  the 
common  duct  by  >tone.  and  in  the  majority  of  cases  (more  than 
three-fourth-'  produced  by  other  form.-  of  obstruction  (Courvoi- 
-ier'-  law).  The  beginning  of  cancer  of  the  gall-bladder  cannot  be 
distinguished  from  cholelithia-i-.  It  i-  only  when  the  nodule-  ap- 
pear locally  and  cachexia  develop.-  that  one  may  be  rea.-onahly 


616 


PRINCIPLES   OF   SURGERY 


certain.  The  liver  is  often  infiltrated,  and  the  growth,  unlike 
cancer  of  the  liver,  spreads  preferably  through  the  lymphatics. 
Hence  the  portal  lymph-nodes  and  viscera  adjacent  to  the  gall- 
bladder are  often  the  site  of  secondary  tumors.  The  peritoneum 
may  be  locally  or  generally  attacked,  and  the  pelvic  organs,  espe- 
cially the  ovaries,  often  contain  metastases.  Cancer  of  the  gall- 
bladder is  more  frequent  in  women.  The  usual  forms  are  the 
cylinder-celled  and  the  round-celled  (glandular  carcinoma), 
either  of  which  may  be  colloid  or  scirrhous,  and  more  rarely  the 
squamous-celled  form,  which  is  presumably  possible  in  such  struc- 
tures by  metaplasia. 


Syncytial. 
ceUs. 


Liver 
cells. 


Fig.  208. — Chorioma  in  liver.     (Microphotograph;  X  about  100.) 

Intestines. — Cancer  of  the  intestines  may  produce,  in  addition 
to  the  usual  signs  and  symptoms  of  this  tumor,  some  form  of  in- 
testinal obstruction  by  compression  of  the  lumen,  by  stenosis  due 
either  to  the  growth  of  the  tumor  or  to  the  contraction  of  the  new- 
formed  connective  tissue,  or  by  volvulus  and  adhesion.  However, 
it  is  marvelous  to  what  extent  the  alimentary  tract  may  be  in- 
vaded without  symptoms  of  obstruction  arising.  When  intestinal 
obstruction  from  this  source  arises  it  may  be  either  acute  or  chronic. 

Chorion  Epithelioma. — One  type  of  cancer  remains  to  be  dis- 
cussed briefly,  namely,  malignant  chorion  epithelioma,  or  syn- 
cytioma  malignum.  This  tumor  arises  only  from  the  epithelial 
cells  of  the  chorionic  villi,  the  syncytium.  These  tumors  occur 
only  in  women  who  have  been  pregnant  recently,  whether  that 


CANCER 


617 


pregnancy  was  intra-uterine  or  extra-uterine;  whether  it  was 
terminated  by  an  abortion  or  by  normal  labor,  and  in  women  who 
carry  a  hydatid  mole  or  who  have  recently  been  delivered  of  one. 
The  tumor  may  originate  before  the  delivery  of  a  mole  (malignant 
hydatid  mole)  or  after  its  delivery.  It  is  instructive  to  note  that 
half  the  cases  of  malignant  chorion  epithelioma  are  associated  with 
or  follow  hydatid  moles.  The  development  of  chorion  epithelioma 
takes  place  by  an  exaggeration  of  the  normal  cellular  processes  of 
pregnancy.  Normally  the  chorionic  villi  penetrate  through  the 
uterine  mucosa  into  the  superficial  (internal)  muscular  layers 


Fig.  209. — Chorioma  in  liver.    Same  as  Fig.  208.     Showing  large  multinu- 
cleated  wandering  syncytial  cells.     (Microphotograph;  X  about  250.) 

and  into  the  veins.  The  villi  when  normal  may  even  yield  small 
eniholi,  which,  carried  by  the  venous  blood,  lodge  in  the  lungs  and 
disappear.  In  the  development  of  chorion  epithelioma  the  masses 
may  grow  through  the  whole  musculature  of  the  uterus,  and  the 
growths  into  the  veins  are  coarse  and  numerous.  The  nature  of 
the  growtli  and  its  behavior  toward  the  veins  render  it  likely 
to  l»e  confused  with  sarcoma;  it  has,  indeed,  been  mistakenly 
named  sarcoma  deciduocellulare.  The  re:idiin--s  with  which  the 
veins  are  penetrated  accounts  for  the  early  metastases,  the  tend- 
ency of  the  primary  growth  and  its  metaMa-es  toward  henior- 


618  PRINCIPLES   OF   SURGERY 

rhage,  for  the  variegated  color  of  the  cut  surfaces,  red,  yellow, 
and  mottled,  and  for  the  early  metastasis  and  the  rapidly  fatal 
termination  and  the  hopelessness  of  the  condition.  Metastasis 
occurs  very  early,  and  is  usually  already  present  when  the  tumor 
is  discovered.  These  metastases  are  most  common  in  the  lungs 
where  they  may  cause  hemoptysis;  the  next  site  is  the  vagina,  in 
which  they  form,  it  is  claimed,  by  reverse  flow  in  the  vaginal  veins. 
The  brain  is  also  a  frequent  site  of  metastasis  and  so  are  the  kid- 
neys; in  the  latter  it  may  be  first  shown  by  hematuria. 

Chorion  epithelioma  manifests  itself  at  any  time  during  preg- 
nancy, normal  or  abnormal,  or  in  from  two  weeks  to  several  years 
(four)  after  delivery,  miscarriage,  or  abortion.  The  earliest  symp- 
tom may  be  either  pain  or  hemorrhage.  The  pain  is  felt  in  the 
pelvis  and  in  the  sacral  and  lumbar  region,  and  may  be  moderate 
or  severe.  Hemorrhage  is  an  important  symptom,  profuse,  inter- 
mittent, and  unyielding  to  the  usual  means  employed  for  its  control 
at  such  times.  In  malignant  hydatid  mole,  or  where  the  syncyt- 
ioma  is  present  at  the  time  of  labor,  fatal  postpartum  hemorrhage 
is  probable.  Between  the  hemorrhages  there  is  a  continuous  foul 
watery  or  sanious  discharge.  Soon  decomposition,  stench,  and 
passage  of  disintegrating  clots  occur.  The  remaining  symptoms 
are  such  as  attend  cancer  of  the  uterus,  but  are  intensified.  The 
patient  rapidly  becomes  cachectic,  emaciated,  and  progressively 
weakened,  dying  hi  a  few  weeks,  or  at  most  in  a  few  months  from 
hemorrhage,  exhaustion,  or  embolism.  This  is  the  most  rapidly 
fatal  form  of  malignant  epithelial  tumor. 

Variations. — Cancer  may  be  predominantly  cellular,  the 
medullary  type;  or  it  may  contain  relatively  few  cells  and  an 
abundance  of  stroma,  scirrhus;  or  these  elements  may  be  rather 
equally  distributed  throughout  the  tumor,  the  simple  form  of 
cancer.  The  arrangement  of  cells  relative  to  the  stroma  may  give 
the  suggestion  of  eggs  in  nests,  nest-celled  cancer.  Cancer  does 
not  appear  often  as  a  mixed  tumor,  for  the  cancer  cells  usually  soon 
dominate  the  field  even  in  those  cases  where  the  malignant  growth 
develops  on  a  pre-existing  benign  growth.  The  important  lesson 
in  this  connection  is  that  the  cancer  may  be  confined  to  a  limited 
area  of  a  pre-existing  lesion,  ulcer,  tumor,  or  cyst,  and  a  definite 
answer  cannot  be  made  by  the  pathologist  without  extensive  sec- 
tion of  the  growth.  In  every  case  where  microscopic  diagnosis 
must  be  depended  on,  the  entire  tumor  should  be  submitted,  or  the 
section  should  be  chosen  from  the  more  suspicious  region  and  from 
a  growing  portion,  not  from  the  older  portions  of  the  tumor,  which 
may  have  degenerated  to  such  an  extent  as  to  lose  all  their  char- 
acteristic features.  It  is  easy  to  understand  how  a  microscopic 
examination  may  in  the  most  skilful  hands  show  no  evidence 


CANCER  619 

of  cancer  when  small  specimens  are  selected  at  random,  as  from 
uterine  scrapings.  The  statements  made  concerning  microscopic 
diagnosis  in  the  chapter  on  Sarcoma  obtain  here,  with  the  ex- 
ception that  there  is  less  danger  probably  of  exciting  metastases 
1'V  exci-ing  {xntions  of  cancer  than  is  the  case  in  sarcoma. 

Cancer  rarely  appears  as  a  mixed  malignant  tumor,  carcinoma 
<arcomatode-.  in  which  the  sarcomatous  cells  arise  as  a  true 
btetomatoua  development  from  the  cancer  stroma.  Another 
very  interest  ing  possibility  in  the  lodgment  of  cancer  metastases 
is  a  pre-existing  benign  tumor. 

The  pathologic  changes  which  befall  cancerous  tissues  are 
determined  by  their  position  relative  to  a  mucous  or  cutaneous  sur- 
face, the  structure  in  which  they  appear,  and  certain  accidents 
which  may  befall  them. 

Ulceration  is  the  most  frequent  accident  of  skin  cancer,  being 
:t  In  lost  universal;  it  is  likewise  very  common  in  cancers  affecting 
mucous  surfaces.  Traumatism,  infection,  and  the  action  of  digest- 
ive fluids  on  necrotic  tissue  play  their  respective  parts  in  the 
production  of  ulcer.  Necrosis  of  cancerous  tissue  is  exceedingly 
common,  especially  in  the  larger  growths,  not  from  a  want  of  an 
adequate  vascularization,  but  from  the  fact  that  there  is  no  definite 
arrangement  of  these  vessels  which  will  determine  a  steady  flow 
of  Mood.  Fatty  degeneration  is  a  very  frequent  change,  especially 
in  cancer  of  the  skin  or  of  the  breast.  Myxomatous  and  colloid 
change-  are  occasionally  seen. 

Infection,  inflammation,  suppuration,  and  gangrene  of  ex- 
posed cancerous  tissue  are  very  frequently  observed. 

Prognosis. — The  prognosis  depends  upon  the  type  of  the  tumor, 
it-  location,  its  complications,  and  the  stage  of  advancement  at  the 
time  application  is  made  for  treatment.  It  also  depends  partially 
upon  the  age  ami  general  condition  of  its  host. 

The  outlook  for  untreated  cancer  is  altogether  bad,  for  every 
untreated  cancer,  nay  more,  every  cancer  whose  treatment  is  not 
undertaken  prior  to  a  certain  state  of  its  development,  is  sure  to 
kill:  and  it  i<  indeed  imperative  that  we  understand  that  in  conse- 
quence of  our  inability  to  recognize  cancer  early  in  many  of  its 
location-,  the  tendency  on  the  part  of  patients  to  conceal  suspicious 
growths,  and  the  ignorant  advice  of  friends  and  unfortunately 
-ometime-  of  medical  attendants  to  await  development,  the  mor- 
tality from  cancer  in  general  i>  probably  far  in  excess  of  50  per  cent. 
of  the  cases,  and  certainly  greatly  over  50  per  cent,  if  we  omit 
cancer-  of  the  -kin.  When  one  take-  into  consideration  the  fact 
that  of  every  s  death-  1  i-  from  cancer,  ami  the  additional  fact  that 
it  i-  un<|iie-tional>ly  on  a  >teadily  progre— ive  increase,  as  is  shown 
•li\  record-  of  the  older  ho-pital-.  and  that  thi-  increase  can  be 


620  PRINCIPLES   OF   SURGERY 

only  partially  explained  by  more  accurate  diagnostic  methods, 
one  is  indeed  impressed  with  the  significance  of  the  cancer  problem. 

Cancer  is  always  a  curable  condition  for  a  certain  period  of  its 
existence,  for  it  is  unquestionably  very  narrowly  a  local  process. 
Unfortunately,  this  stage  of  cancer  is  devoid  of  symptoms  and 
signs  except  when  it  is  very  superficial.  Contrariwise,  after  a 
certain  other  period  of  time,  variable  in  different  types  and 
different  locations,  during  which  the  tumor  is  local,  but  em- 
braces structures  more  or  less  remote  from  the  primary  growth, 
it  is  regional.  In  this  case  the  cancer  is  still  curable,  if  one  can  be 
fortunate  enough  to  remove  all  the  cancer-bearing  tissue,  a  possi- 
bility that  one  can  never  know  when  one  has  attained.  Or, 
being  regional,  a  part  of  the  affected  tissue  may  be  manifestly 
unremovable  on  account  of  the  vital  importance  of  the  structures 
attacked.  Later,  in  the  majority  of  cancers  a  still  more  extensive 
distribution  of  the  growth  takes  place;  it  becomes  general  from  a 
practical,  and  often  enough,  indeed,  from  a  literal,  viewpoint. 
Metastases  have  occurred  throughout  important  organs. 

From  the  standpoint  of  the  cancer  type  it  may  be  said  that 
the  squamous-celled  tumors  offer  the  best  prognosis.  Hence, 
as  an  illustration,  we  may  cite  cancer  of  the  skin,  which  is  curable 
in  the  vast  majority  of  cases  if  taken  in  hand  at  a  reasonable 
time,  a  factor  rendered  possible  by  the  superficial  site  of  these 
growths.  The  glandular  forms  are,  as  a  whole,  much  less  amen- 
able to  treatment  both  on  account  of  their  nature  and  their  deeper 
situation.  The  average  life  of  a  patient  with  the  former  type  of 
tumor  is  five  to  ten  years,  while  that  of  those  who  have  glandular 
tumors  is  from  six  months  to  two  or  three  years.  Of  the  glandular 
type,  the  greater  the  supply  of  connective  tissue,  the  greater  the 
expectancy.  Thus  the  order  of  death  would  be,  first,  in  the  medul- 
lary or  encephaloid  type,  in  which  in  the  acute  forms  the  growth 
may  be  so  rapid  as  to  be  mistaken  for  an  inflammatory  process, 
and  occurs  early,  in  six  to  twelve  months;  second,  from  the  simple 
form  in  which  the  stroma  and  parenchyma  are  about  equally 
abundant,  and  which  produces  death  in  from  eighteen  months  to 
three  years;  third,  the  scirrhous  type,  which  kills  in  from  five  to 
fifteen  years. 

Cancer  kills  its  host  in  various  ways:  First,  of  course,  it  may 
and  will  kill,  barring  accidents  and  complications,  by  exhaustion, 
anemia,  and  cachexia.  Second,  it  may  kill  its  host  suddenly  or  by 
degrees  by  hemorrhage.  This  may  be  the  cause  of  sudden  death 
in  cancers  of  the  uterus,  stomach,  rectum,  or  bladder,  but  repeated 
hemorrhages  of  varying  degree  are  more  common  by  far  than 
fatal  hemorrhages.  Cancers  do  not  bleed  into  the  tumor  substance 
nearly  as  frequently  as  sarcomata  do.  Third,  infection  may  be* 


CANCER  621 

mild  and  contribute  only  a  part,  or  it  may  be  altogether  respon- 
sible for  the  patient's  death  by  the  local  action  of  the  bacteria  or 
by  the  causation  of  a  general  septic  condition.  Fourth,  the  general 
wa>ting,  in  the  absence  of  definite  hemorrhage,  by  the  loss  of  body 
fluids  with  more  or  less  admixture  of  blood,  may  hasten  the  end, 
Fifth,  embolism  may  be  the  cause  of  sudden  death,  and  is  more 
especially  likely  to  occur  in  the  advanced,  inoperable  cases, 
ially  as  a  consequence  of  manipulation  or  of  a  palliative 
operation.  The  source  of  the  embolus  may  be  either  a  mass  of 
cancer  tissue  liberated  in  a  vein,  or  a  blood-clot  which  has  formed 
cither  simply  on  account  of  blockage  of  the  circulation  or  by  the 
pn-ence  of  infection.  Thrombosis  may  be  the  direct  cause  of 
death  in  cases  of  cancer,  but,  as  a  matter  of  fact,  does  not  fre- 
quently do  so.  Sixth,  various  accidents  which  interfere  with 
normal  function  may  cause  death.  Cancer  of  the  larynx  may 
cause  it  by  asphyxiation;  of  the  esophagus,  cardia,  or  pylorus, 
by  starvation;  of  the  intestine,  by  intestinal  obstruction,  acute 
or  chronic;  of  the  rectum,  by  autotoxemia  from  fecal  retention; 
of  the  liver,  by  blockage  of  the  bile-channels,  which  produces 
cholemia,  or  by  destruction  of  the  portal  circulation,  which  results 
hi  inanition  and  ascites. 

Acute  or  encephaloid  cancer,  growing  rapidly  in  a  young 
patient,  in  general  offers  a  very  poor  prognosis. 

The  prognosis  of  skin  cancer  is  better  than  that  appearing  in 
any  other  structure,  and  if  the  cases  are  treated  according  to  the 
mo-t  approved  methods  and  are  taken  in  charge  at  a  reasonable 
time,  they  would  give  a  percentage  of  cures  approximating  or  possi- 
bly weeding  90  per  cent.  Cancer  of  the  tongue  should  likewise 
give  u-ually  a  high  percentage  of  cures  on  account  of  the  ease  of 
early  recognition,  but,  as  a  matter  of  fact,  cures  are  exceptional 
becau-e  patient-  who  have  cancer  of  the  tongue  usually  stubbornly 
resist  proper  treatment  until  they  have  advanced  to  a  hopeless 
stage.  Early  radical  treatment  shows  very  satisfactory  results. 
Cancer  of  the  breast,  as  the  cases  (operable)  come,  have  in  the  best 
records  a  percentage  of  cures  approximating  50  per  cent.  On  the 
average,  from  combined  -tatisties,  its  percentage  would  fall  con- 
siderably below  thi-  maximum.  Cancer  of  the  stomach  is  ex- 
ceedingly unfavorable  in  it-  outlook.  The  usual  stage  of  advance- 
ment and  the  impossibility  of  making  satisfactory  clinical  diagnosis 
militate  against  a  satisfactory  opportunity  to  do  promising  work 
in  thi-  condition.  The  number  of  euro  varie-.  very  materially  in 
different  report <  and  on  account  of  the  part  of  the  stomach  affected. 
Pyloric  cancer  is  mo>t  amenable  to  surgical  treatment  'there  i-  no 
other  treatment  ).  The  average  number  of  cures  beyond  the 
three-year  limit  ranges  probably  between  20  and  30  per  cent,  at  the 


622  PRINCIPLES   OF   SURGERY 

present  time,  and  has  been  increasing  rapidly  during  the  last 
decade.  This  promises  very  favorably  for  the  probability  of  cure 
hi  gastric  cancer  when  we  once  have  learned  to  advise  exploratory 
incision  on  grave  suspicion  and  cease  to  wait  for  clinical  finding* 
to  determine  the  presence  of  cancer.  I  would  not,  however, 
convey  the  idea  that  all  clinically  recognizable  cancers  are  inop- 
erable or  that  all  those  discovered  by  exploration  are  operable. 
The  question  can  be  settled  only  by  opening  the  abdomen  and 
inspecting  the  field.  A  moderately  high  mortality  attaches  to 
partial  gastrectomy  and  a  very  high  mortality  to  complete  gas- 
trectomy.  Cancer  of  the  uterus  presents  one  of  the  gloomiest  and 
most  disheartening  pictures  the  surgeon  has  to  contemplate; 
theoretically,  looking  as  if  it  should  promise  a  rather  favorable 
field  for  cure,  each  surgeon's  experience,  whether  large  or  small, 
proves  it  to  be  one  of  the  very  most  hopeless  of  surgical  lesions. 
The  ultimate  recovery  of  these  cases  is  covered  by  something  less, 
probably  very  much  less,  than  10  per  cent.  In  reality  it  is  not 
likely  much  more  than  5  per  cent.  Late  diagnoses  are  here,  too, 
responsible  for  somewhat  of  the  small  number  of  cures,  but  not 
entirely.  No  man  can  say  whether  a  uterine  cancer  is  operable 
until  he  has  explored  the  pelvis  through  an  abdominal  incision 
(Wertheim).  Cancer  of  the  liver  is  almost  absolutely  hopeless; 
the  only  type  that  can  possibly  become  amenable  to  excision  is  a 
single  nodule  situated  near  the  surface  or  the  margin  of  the  organ. 
Cancer  of  the  bladder,  whether  treated  by  removal,  partial  resec- 
tion, or  total  extirpation,  shows  permanent  cures  of  10  per  cent, 
and  less,  average  about  7  per  cent.  Cancer  of  the  rectum  is  more 
fatal  both  as  to  operative  mortality  and  recurrence  in  young 
patients,  i.  e.,  under  thirty  years  of  age;  both  decrease  gradually 
until  the  age  of  fifty.  Between  fifty  and  sixty  years  is  the  period 
that  gives  the  smallest  operative  mortality,  about  12  per  cent., 
and  the  smallest  percentage  of  recurrence,  60  per  cent.  (Tuttle). 
Cancer  of  the  esophagus  may  be  accepted  now  as  invariably  fatal ; 
since  the  advent  of  differential  pressure  methods  for  intrathoracic 
surgery  there  has  been  considerable  effort  to  perfect  a  technic  for 
resection  of  the  esophagus,  but,  while  the  results  are  somewhat 
encouraging,  the  cases  are  not  sufficiently  numerous  to  offer  much 
hope  of  recovery. 

The  remaining  sites  of  cancer  are  of  minor  importance,  so  far  as 
frequency  is  concerned,  as  compared  with  those  discussed  above; 
and  the  factors  which  influence  the  prospect  have  been  discussed 
with  sufficient  elaborateness  to  render  the  reader  capable  of  form- 
ing a  correct  prognosis  without  discussion  in  detail. 

That  spontaneous  recovery  from  cancer  has  occurred  is  un- 
doubted, but  it  is  so  rare  an  occurrence  that  no  hope,  utterly  none, 


CANCER  623 

can  be  offered  by  the  physician.  He  does  his  duty  when  he  tells 
his  patient  that  cancer  kills  and  always  kills  when  left  to  itself. 

The  outlook  in  cancer  cases  then  is  gloomy  because  the  cancer 
is  not  attacked  early  enough,  and  about  the  only  hope  at  present 
is  to  disseminate  a  correct  knowledge  of  the  facts,  so  that  patients 
will  apply  on  slighter  suspicion  of  disease,  and  submit  to  radical 
procedures  on  microscopic  rather  than  on  clinical  evidence. 

Treatment. — Treatment  is  divisible  into  curative  and  palliative, 
applicable  respectively  to  operable  and  to  inoperable  cancer. 
These  terms  have  already  been  defined  under  Sarcoma,  but 
repetition  is  pardonable.  An  operable  cancer  is  one  which  offers 


I  iu    'J10.     Kyrlids.  eye,  orbital  tissue,  and  floor  of  orbit  removed  for  epithr- 
lioma  of  lower  lid.     The  lower  opening  Ls  into  the  antrum  and  nasal  cavity. 

u  possibility  of  removal  of  the  entire  mass  of  cancer  cells  and  which 
( >tTers  an  operative  and  an  ultimate  recovery.  An  inoperable  cancer 

fails  in  one  or  both  of  these  respects. 

The  curative  treatment  of  cancer  contemplates  the  complete 

removal  or  destruction  of  the  tumor  by  whatever  means  it  is  to  be 
accomplished.  So  lon^  as  a  -injje  cancer  cell  capable  of  growth  and 
situated  favorably  remains  in  the  body,  the  patient  is  not  cured. 
Since  it  i-  imp<i--iMr  to  know  just  how  far  the  growth  has  ex- 
tended, it  i-  manifest  ho\v  one  can  never  be  absolutely  positive 
that  cancer  has  been  cured.  The  means  employed  for  the  cure 
of  cancer  are  operation,  cauteri/at ion,  r-ravs  and  radium,  fulgura- 
tion  and  c-chan>tic-.  or  combinations  of  these. 


624  PRINCIPLES   OF   SURGERY 

The  operative  treatment  of  cancer  can  be  a  rational  procedure 
and  can  offer  the  best  results  only  when  it  is  based  upon  an  ac- 
curate understanding  of  the  behavior  of  cancerous  tissue  relative 
to  the  normal  tissues,  especially  its  capacity  to  infiltrate,  to  attack 
the  lymph-nodes  either  by  direct  extension  or  by  the  escape  of 
cancer  cells  into  the  lymph-stream,  its  metastases,  and  the  capacity 
of  implantation  grafts.  Certain  practical  conclusions  have  been 
drawn  from  a  just  consideration  of  these  factors,  and  failure  to 
abide  by  them  may  result  disastrously  for  the  patient.  Owing  to 
the  tendency  to  infiltrate,  often  far  beyond  the  limits  of  clinical 
evidence,  the  first  requirement  in  the  excision  of  cancer  is  that  the 
incision  shall  be  made  relatively  wide  of  the  cancer  limits  and 
that  if  possible  the  organ  hi  which  the  tumor  appears  should  be 
excised.  This  rule  is  modified  by  resection  of  a  part  of  the  organ 
if  it  is  of  vital  importance  and  if  the  tumor  is  small.  The  sacrifice 
of  tissue,  skin,  muscle,  bone,  whatever  it  may  be,  is  considered 
necessary  if  there  is  any  question  of  its  invasion.  Second,  the 
tumor  and  the  lymph-nodes  into  which  it  is  likely  to  spread  are 
both  to  be  removed,  preferably  en  masse,  whether  they  show  signs 
of  enlargement  or  not.  This  means  not  only  that  nodes  and  tumors 
are  to  be  cleared  out,  but  the  entire  group  of  nodes  and  lymph- 
channels  connecting  them  with  the  tumor.  For  if  cancer  extends 
its  root-like  processes  along  the  lymph-channels,  to  leave  them 
would  mean  certain  recurrence  of  the  tumor. 

On  account  of  the  possibility  of  metastasis  it  is  necessary  that 
the  tumor  shall  be  handled  as  gently  and  manipulated  as  little  as 
possible  prior  to  and  during  the  operation,  and  it  should  also  be  a 
rule  of  common  practice  to  ligate  the  important  vessels  which 
supply  the  tumor  early  in  the  operation,  so  that  if  the  necessary 
manipulation  should  dislodge  an  embolus  it  cannot  be  carried 
away  from  its  place. 

The  possibility  of  implantation  grafts  serving  as  the  cause  of 
recurrence  is  not  sufficiently  impressed.  The  tumor,  the  lymph- 
nodes,  all  cancer-bearing  tissue  should  be  excised,  not  dug,  torn, 
or  curetted  out,  and  the  instruments  should  never  come  in  contact 
with  cancer  cells  nor  the  latter  be  allowed  to  come  hi  contact  with 
the  raw  surfaces  of  the  wound.  Unquestionable  cases  of  this  form 
of  recurrence  have  been  reported,  and  if  the  truth  were  known 
they  would  doubtless  be  much  more  numerous.  If  it  is  necessary 
to  cut  into  cancerous  tissues  for .  microscopic  specimens,  or  if  it 
be  done  accidentally,  the  tissues  should  be  guarded  from  con- 
tamination just  as  assiduously  as  one  would  guard  the  peritoneum 
against  an  infected  focus.  The  cut  cancer  surface  should  imme- 
diately be  cauterized  with  carbolic  acid  or  Harrington's  solution 
and,  if  possible,  closed  by  sutures. 


CANCER 


025 


Illustrative  of  the  operative  treatment  of  cancer  two  examples 
will  l>e  given,  namely,  cancer  of  the  breast  and  of  the  penis.  In 
cancer  of  the  breast  the  whole  of  the  organ,  a  varying  area  of  sur- 
rounding skin  and  fat,  the  pectoral  muscles,  and  the  axillary  fat 
which  contains  the  lymph-nodes,  are  all  to  be  removed  by  single 
block  dissection,  working  preferably  from  above  downward  and 
ligating  early  the  vessels  coming  downward  from  the  axillary 
artery.  It  may  be  necessary  to  extend  the  incision  above  the 
clavicle  and  to  remove  the  supraclavicular  fat  and  nodes.  If 
on  removal  of  this  tissue  it  is  found  that  the  tumor  has  attacked  the 


I  i^.  211. — Dissection,  required  to  remove  growth  shown  in  Fig.  179. 

thoracic  wall,  it  too  requires  to  be  resected,  preferably  under  dif- 
ferential pressure.  Certain  surgeons  spare  the  pectoral  muscles, 
simply  cleaning  away  the  lymph-bearing  fascia. 

If  the  penis  is  affected,  the  whole  of  the  body  of  the  organ 
back  to  the  osseous  attachments,  and  the  lymphatics  of  the  groin 
with  the  connecting  lymph-channels  and  connective  tissue,  must 
be  dissected  away  in  one  mass. 

From  what  has  already  been  stated  concerning  the  require- 
ments for  the  cure  of  cancer,  to  the  effect  that  every  vestige  of  the 
growth  must  be  removal,  it  is  needless  to  state  that  l»y  whatever 

40 


626  PRINCIPLES    OF    SURGERY 

means  this  end  is  accomplished,  cure  will  follow.  The  employ- 
ment of  the  actual  cautery  has  been  resorted  to  hi  the  past  with 
considerable  frequency  for  the  destruction  of  cancerous  tissue 
with  a  view  of  producing  a  cure.  It  is  used  at  the  present  time  for 
the  same  purpose,  but  with  much  more  restriction.  The  devious 
paths  of  infiltration  and  the  growth  of  the  cancer  mass  hi  slender 
processes  along  the  lymph-channels  would  teach  the  danger  of 
leaving  unharmed  portions  of  the  tumor  in  situ  to  continue  its 
growth  perhaps  even  with  increased  vigor.  Naturally,  this  plan 
of  treatment  is  feasible  only  in  cancers  of  the  skin,  possibly  also  of 


Fig.  212. — Showing  result  of  removal  of  right  ear,  parotid  gland,  and  the 
surrounding  skin  for  a  large  epithelioma  of  lower  half  of  ear.  Treated  with 
x-rays  immediately  after  operation. 

the  mucous  membrane  of  the  mouth.  And  if  one  can  be  sure  that 
no  widespread  infiltration  has  occurred  and  that  no  invasion  of  the 
regional  lymph-nodes  has  taken  place,  that  is,  if  the  tumor  is 
confined  to  narrow  superficial  limits,  it  cannot  be  doubted  that 
cure  may  be  obtained  in  this  way.  The  greater  field  that  may 
be  covered  by  careful  dissection,  and  the  more  definite  accuracy 
with  which  diseased  or  suspected  tissues  may  be  removed  without 
harm  to  the  related  structures,  have  led  the  majority  of  surgeons 
to  abandon  the  actual  cautery  in  favor  of  the  scalpel.  When  cauter- 
ization is  chosen  as  the  most  suitable  agent,  it  should  be  done 
with  an  instrument  heated  to  a  dull-red  ("cherry")  hue,  so  as  to 


CANCER  627 

accomplish  hemostasis  at  the  same  time.  The  tissues  should  be 
cauterized  for  some  distance  in  every  direction  from  the  tumor 
mass.  There  is  no  doubt  that  cauterization  properly  done  is  a 
much  more  satisfactory  plan  than  the  next  to  be  discussed,  namely, 
escharotics;  however,  it  is  accepted  now-a-days  usually  as  an 
adjuvant  to  be  employed  as  a  preliminary  step  and  to  be  followed 
up  by  some  more  reliable  agent.  The  value  of  cauterization  hi  the 
treatment  of  inoperable  cancer  and  for  relief  of  certain  complica- 
tions will  be  discussed  later. 

Similarly  to  cauterization,  escharotic  drugs  (potential  cautery) 
are  employed  occasionally  for  the  removal  of  cancer,  again  super- 
ficial. They  were  formerly  employed  very  extensively,  but  are 
now  left  as  the  remedy  of  choice  to  that  vampire  of  modern 
medicine,  the  cancer  quack.  The  same  rule  obtains  hi  this  as  in 
cauterization,  viz.,  if  all  the  tumor  cells  are  destroyed,  cure  results; 
and  if  not,  no  cure  follows.  The  selective  action  of  escharotics  for 
cancerous  tissue  in  preference  to  adjacent  normal  tissue  I  have  not 
been  able  to  see  verified,  although  I  have  had  the  privilege  of  ex- 
amining many  such  specimens.  The  tissues  are  destroyed  in  toto 
to  a  certain  depth  and  the  eschar  is  thrown  off  by  the  healing 
process.  The  drugs  used  by  preference  are  some  preparation 
of  arsenic,  especially  arsenious  acid  or  the  chlorid  of  zinc.  The 
most  popular  formulas  employed  were  known  as  Vienna  paste  and 
London  paste.  There  is  no  doubt  that  many  cures  have  been 
produced  by  these  drugs;  there  is  less  doubt  that  unnumbered 
hosts  have  gone  to  their  graves  because  this  line  of  treatment  was 
given  preference  over  unquestionably  more  efficient  plans. 

The  discovery  of  x-rays  brought  into  the  therapeutics  of 
cancer  the  most  astonishing  and  satisfactory  remedy  that  the 
profession  has  yet  known.  The  dangers  of  this  form  of  electricity 
to  both  patient  and  physician  cannot  be  entered  into  in  this 
connection.  Suffice  it  to  say  that  the  first  lesson  to  be  learned 
in  reference  to  this  plan  is  that  the  treatment  of  any  lesion  by 
r-rays  should  be  left  entirely  in  the  hands  of  those  who  are  skilful 
in  their  use  and  who  have  had  sufficient  experience  to  escape  the 
serious  blunders  that  may  befall  the  novice.  It  is  needful  also  to 
emphasize  the  fact  that  x-rays  are  not  a  panacea  for  cancer. 
The  number  of  cancers  amenable  to  this  treatment  is  compara- 
tively limited,  embracing  only  those  which  appear  on  the  skin  or 
the  ea-ily  accessible  mucous  membranes,  as  in  the  mouth;  nor  is 
it,  indeed,  capable  of  cure  in  all  of  these.  The  deeper  tumors  are 
not  rural ile  by  this  treatment,  and  in  a  general  way  cancer  of  the 
mucous  memlirane  is  much  le—  -u-ceptible  to  it  than  cancer  of  the 
skin.  The  deii-er  the  tissue  to  be  penetrated  by  the  rays  before 
reaching  the  cancer  cells,  and  the  thicker  the  tissue  lying  be- 


628  PRINCIPLES    OF    SURGERY 

tween  them  and  the  surface,  the  less  efficiently  do  the  rays  destroy 
them.  Hence,  the  most  adaptable  field  for  the  employment  of 
x-rays  as  a  cure  is  in  thin  superficial  cancers.  Deception  of  both 
patient  and  physician  often  occurred  while  the  profession  was 
learning  this  lesson,  for  the  ulcerating  surface  of  a  cancer  may  be 
made  to  heal  almost  like  a  wound  healing  by  second  intention, 
while  the  deeper  portions  of  the  tumor  are  retarded  little  if  any  by 
the  attenuated  rays  that  chance  to  reach  them.  Therefore,  in  all 
cases  of  deep  cancer  no  attempt  need  be  made  to  produce  a  cure, 
whether  the  cancer  originated  deeply,  or  has  by  infiltration,  metas- 
tasis, or  lymphatic  involvement  grown  deeply  into  the  tissues. 
It  is  all  one;  the  rays  do  not  penetrate  the  tissues  sufficiently  to 
kill  the  growth,  although  they  may  retard  it.  Another  feature  of 
x-ray  treatment  of  cancer  is  the  influence  it  has  in  alleviating 
pain,  even  hi  inoperable,  incurable  cases.  Inoperable  cancers 
are  sometimes  materially  reduced  hi  size  and  retarded  hi  growth 
by  x-rays.  Radium  and  Finsen  rays  are  employed  in  a  manner 
similar  to  that  of  x-rays  and  with  fairly  good  results,  although 
the  latter  treatment  is  almost  universally  used  to  the  exclusion 
of  the  former  two. 

Fulguration  is  a  plan  of  electric  treatment  devised  by  de  Keat- 
ing-Hart, of  Paris.  This  treatment  is  still  in  its  infancy,  having 
been  first  published  about  five  years  ago,  but  the  results  so  far 
reported  by  him  would  indicate  that  it  is  a  valuable  adjunct  to  the 
treatment  of  cancer.  It  must  be  emphasized,  too,  that  it  is  cura- 
tive only  when  the  macroscopic  tumor  mass  has  been  removed 
by  excision.  Even  when  complete  removal  of  the  tumor  is  im- 
possible, this  treatment  renders  service  by  relieving  pain,  by 
control  of  hemorrhage,  and  other  troublesome  or  dangerous 
complications,  de  Keating-Hart  advocates  thorough  removal  of 
the  tumor  and  immediate  fulguration  of  the  wound,  and  claims 
and  apparently  proves  that  recurrence  will  be  less  frequent  or 
longer  delayed,  that  many  can  be  cured  by  this  plan  who  would 
fail  to  be  cured  (who  have  indeed  failed)  by  other  plans,  and  that 
considerably  longer  expectancy  can  be  offered  in  many  hopeless 
cases.  The  time  of  treatment  averages  about  one  minute  per 
square  centimeter.  Anesthesia  is  imperative. 

The  ideal  treatment  in  many  cases  of  cancer  is  a  combination 
of  two  of  these  methods.  In  those  cases  which  are  pre-eminently 
amenable  to  x-rays,  but  hi  which  the  mass  of  tumor  tissue  is  so 
great  as  to  offer  a  possible  prevention  of  cure,  it  is  absolutely  neces- 
sary that  the  tumor  shall  be  removed  by  excision  or  destroyed  by 
the  actual  cautery  prior  to  beginning  the  x-ray  treatments.  In 
such  cases  the  wound  should,  when  it  is  at  all  feasible,  be  permitted 
to  remain  open,  so  that  direct  exposure  of  any  residual  cancer 


CANCER  629 

cell-  may  be  obtained.  In  those  cases  in  which  the  treatment  is 
par  excellence  operative,  it  is  a  wise  plan  to  expose  the  field  to 
.r-rays  to  produce  a  redoubled  assurance  that  no  vestige  of  can- 
cerous tissue  shall  escape.  This  may  be  done  prior  to  closure  of 
the  wound  or  subsequent  to  healing.  The  former  plan  is  imprac- 
ticable in  the  majority  of  cases,  and  unless  the  tumor  is  situated 
near  the  surface  of  the  body,  as,  for  example,  in  the  breast  or  the 
penis,  no  benefit  can  be  hoped  for.  The  indications  at  the  present 
time  are  that  fulguration  is  also  a  very  valuable  adjunct  to  opera- 
tive treatment.  It  is  to  be  employed  at  the  completion  of  opera- 
tion, while  the  patient  is  still  anesthetized. 

Treatment  of  Inoperable  Cancer. — The  physician  must  not  lose 
sight  of  the  fact  that  his  services  may  be  of  untold  value  in  cases 
of  incurable  cancer.  The  demand  for  such  treatment  is  for  the 
accomplishment  of  one  or  more  of  the  following  ends:  To  prolong 
the  life  of  the  patient  as  much  as  possible;  to  relieve  pain  and 
discomfort;  to  re-establish  the  possibility  of  necessary  function, 
which  has  been  interrupted  by  the  presence  of  tumor;  to  control 
hemorrhage;  to  prevent  or  correct  decomposition  and  the  at- 
tendant stench,  ulceration,  and  inflammation. 

By  attending  carefully  to  two  factors,  namely,  to  maintain 
nutrition  and  to  prevent  depletion,  much  may  be  done  to  prolong 
the  life  of  cancer  patients.  Especially  is  this  to  be  accomplished 
by  pursuance  of  the  instructions  which  follow,  and  by  the  em- 
ployment of  those  agencies  which  retard  the  growth,  whether 
operation,  x-rays,  radium,  or  fulguration. 

Pain,  when  present  in  cancer,  is  often  excruciating.  The  first 
requisite  is  to  decide  whether  the  pain  arises  from  the  cancer 
itself  or  from  a  complication.  If  the  cancer  itself  is  producing 
the  pain  the  first  idea  should  be  to  relieve  it,  if  possible,  by  the 
resection  or  avulsion  of  the  sensory  nerves  supplying  it.  This 
can  he  done  with  greatest  satisfaction  in  cancer  of  the  mouth  or 
tongue.  If  pain  be  due  to  some  complicating  factor,  correction 
of  this  factor  may  be  possible  and  safe,  and  its  performance 
should  be  demanded  even  though  it  will  not  prolong  life.  In 
all  cases  where  pain  is  present  ar-rays  should  be  thoroughly  tried, 
for  it  is  perhaps  the  most  potent  agent  we  have  for  satisfactory 
relief  of  pain,  and  at  the  same  time  tends  to  retard  the  growth 
ami  often  even  to  reduce  the  size  of  the  tumor.  It  is  useless  to 
expect  .r-rays  to  relieve  the  pain  produced  by  obstruction  and 
>imilar  complications.  If  the  pain  cannot  be  relieved  by  the 
above  or  other  agencies  at  hand,  the  patient  should,  as  much  as 
po->il>le,  lie  made  comfortable  l»y  the  administration  of  anodynes 
and  narcotics,  of  which,  of  cour-e.  morphin  stands  at  the  head  of 
the  list.  Of  all  cases,  the  physician  is  excusable  for  administering 


630  PRINCIPLES    OF    SURGERY 

morphin  for  the  few  days  that  remain  to  the  patient  who  has  in- 
curable cancer. 

The  life  of  incurable  cancer  patients  can  very  frequently  be 
prolonged  by  relief  of  complications  which  interfere  with  nutri- 
tion or  elimination,  and  at  the  same  time  much  unnecessary 
discomfort  be  removed  or  avoided.  In  this  way  the  patient  who 
has  cancer  of  the  esophagus  may  be  treated  by  gastrostomy; 
cancer  of  the  larynx,  by  tracheotomy;  of  the  pylorus,  by  gastro- 
enterostomy;  of  the  small  intestine,  by  entero-enterostomy  or 
resection;  of  the  cecum,  by  enterocolostomy;  of  the  rectum,  by 
colostomy;  of  the  prostate  or  bladder,  by  cystotomy. 

Control  of  hemorrhage  in  cancer  is  frequently  the  greatest 
burden  of  the  physician.  It  is  unnecessary  to  mention  the  ordi- 
nary plans  of  hemostasis  hi  general  use.  They  are  of  service 
here  as  elsewhere,  but  the  conditions  are  different,  and  the  hemor- 
rhage controlled  to-day,  to-morrow  recurs  and  may  result  fatally. 
The  prevention  of  ulceration  and  necrosis  is  of  prune  importance 
in  the  avoidance  of  cancer  hemorrhage;  but  often  these  cannot 
be  prevented  long.  Two  plans  are  especially  applicable  for  this 
purpose,  provided  the  general  condition  of  the  patient  will  permit 
them,  namely,  ligature  of  the  blood-vessels  supplying  the  tumor, 
or  removal  of  the  entire  growth,  if  this  can  be  done  more  safely 
and  more  effectively  than  ligation  in  continuity.  The  superiority 
of  removal  over  ligation  lies  in  the  fact  that  in  the  former  col- 
lateral circulation  will  not  re-establish  the  hemorrhage.  Hemor- 
rhage may  often  be  controlled  by  removal  or  destruction  of  the 
decomposing  portions  of  the  tumor,  as  hi  cauterization,  curetment, 
or  the  application  of  acetone  in  cancer  of  the  cervix  uteri. 

Infection,  ulceration,  decomposition,  and  inflammation  are 
partially  amenable  to  the  same  plans  here  as  elsewhere.  I  say 
partially,  because  the  important  factor  of  resistance  on  the  part 
of  the  living  tissues  to  such  influences  is  either  wanting  or  reduced 
to  a  very  low  state.  Cleanliness,  the  employment  of  antiseptics 
and  deodorants  are  the  plans  upon  which  we  must  rely.  It  is  only 
by  untiring  efforts  that  even  a  modicum  of  relief  can  be  secured  in 
many  cases. 


CHAPTER    XLVII 

CYSTS 

Definition. — A  cyst  may  be  defined  as  a  closed  sac  filled  with 
a  fluid,  semifluid,  or  caseous  substance.  The  sac  may  be  a  vestige 
remaining  from  unobliterated  embryonic  structures,  anatomically 
normal  or  adventitious. 

Structure. — The  structure  of  cysts  is  very  simple.  In  those 
which  form  in  normal  anatomic  spaces  the  sac  is  unchanged, 
except  hi  so  far  as  distention  and  the  formation  of  new  connective 
tissue  added  to  its  outer  surface  cause  an  increase  in  its  thickness. 
In  the  new-formed  cysts  the  sac  is  made  up  of  connective  tissue. 
Those  cysts  arising  from  tumors  are  peculiar  in  this  respect,  namely, 
that  they  have  a  wall  lined  with  one  or  more  layers  of  tumor  cells, 
the  adenocystomata  having  a  distinct  capsule,  which  serves  at  the 
same  time  as  the  fibrous  portion  of  the  sac,  and  cystic  sarcomata 
which  have  no  such  capsule,  the  tumor  cells  alone  forming  a  limit- 
ing wall  to  the  fluid  contents. 

Cysts  are  unilocular,  having  a  single  cavity,  or  multilocular, 
having  more  than  one  cavity;  often  these  cavities  are  numerous. 
In  multilocular  cysts  the  septa  separating  the  various  cavities 
are  constructed  of  the  same  material  as  the  sac. 

The  lining  of  cyst  cavities  may  be  simply  the  normal  epithelial 
or  endothelial  cells  found  in  the  normal  structure  from  which 
the  cyst  arises.  These  cells  may  continuously  cover  the  ul- 
terior surface  of  the  sac  or  only  partially  cover  it,  having  been 
separated  by  excessive  distention.  In  other  instances,  namely, 
in  cysts  of  new  formation,  there  may  or  may  not  be  a  cellular 
lining. 

Contents. — The  contents  of  cysts  vary  so  widely  that  they  can 
be  discussed  adequately  only  hi  connection  with  the  various  cysts 
as  they  are  taken  up  seriatim.  These  contents  are  derived  either 
from  the  lining  of  the  cyst,  from  some  connected  normal  struc- 
ture, or  from  some  accidental  source,  as  in  case  of  hemorrhage  or 
necm-is. 

Characteristics. — The  general  characteristics  of  cysts  are  to  be 
summed  up  in  the  Matement  that  they  are  such  as  would  be  pro- 
duced by  any  well-defined  sac  located  within  the  tissues,  namely, 

631 


632  PRINCIPLES   OF   SURGERY 

as  a  movable,  soft,  boggy,  or  fluctuating  mass.  They  are  well 
defined  in  outline,  much  as  encapsulated  tumors.  Cysts  usually 
grow  more  or  less  in  a  spheric  shape  unless  influenced  by  the 
surrounding  structures.  Aspiration  of  cystic  cavities  usually 
reveals  the  presence  of  the  characteristic  contents  of  the  special 
cyst  in  question.  This  statement  is  not  intended  as  a  recom- 
mendation to  employ  aspiration  as  a  routine  diagnostic  meas- 
ure. The  habitual  sites  of  formation  of  cysts  adds  much  to  the 
facility  of  reaching  an  accurate  diagnosis.  The  rule  is  that 
cysts  are  tightly  distended  by  their  contents,  although  they  are 
sometimes  flaccid.  The  cyst  wall,  instead  of  being  thinned  by 
distention,  is  often  thickened  by  a  heavy  deposit  of  connective 
tissue. 

Complications. — Cysts  are  subject  to  few  complications.  They, 
of  course,  may  become  inflamed  and  rendered  thereby  more  tense 
and  larger,  and  accompanied  with  the  usual  local  and  general 
symptoms  of  inflammation.  Necrosis  or  rupture  of  the  cyst  rarely 
occurs.  If  pus  forms,  the  contents  of  the  cyst  are  modified  accord- 
ingly. 

Classification. — I.  Retention  cysts. 

1.  Sebaceous. 

2.  Mucous. 

3.  Cysts  of  glands  and  their  ducts. 

(a)  Kidney — hydronephrosis. 

(6)  Gall-bladder. 

(c)  Pancreas. 

(d)  Salivary  glands  and  ducts. 

(e)  Vulvovaginal  glands. 
(/)  Breast. 

•  (g)  Meibomian  glands,  Chalazion. 
(h)  Sudamina. 
(i)   Lymphatic. 
(k)  Chyle  cysts. 
(I)    Nabothian  cysts. 
II.  Exudation  cysts. 

1.  Hydrocele. 

2.  Bursal  cysts. 

(a)  Miners'  elbow. 
(6)  Weavers'  bottom. 

(c)  Housemaids'  knee. 

(d)  Boyer's  cyst. 

3.  Hydrothorax,  ascites,  and  hydroperi- 
cardium — not  classed  as  conventional 
cysts. 

III.  Extravasation  cysts. 


CYSTS  633 

IV.  Embryonal  cysts. 

1.  Thyroglossal  or  thyrolingual. 

2.  Branchial. 

3.  Urachal. 

4.  Hydrocele  of  the  cord. 

5.  Sequestration. 

6.  Urogenital. 

7.  Vitello-intestinal. 

8.  Kidney  and  liver. 

9.  Cholesteatoma. 
10.  Dentigerous. 

V.  Cysts  of  new  formation. 

1.  Of  soft  parts — hemorrhagic. 

2.  Of  bones. 

3.  Of  tumors. 

(a)  Cystadenoma. 

(1)  Mammary. 

(2)  Ovarian. 
(6)  Of  sarcomata. 

4.  Necrotic. 
VI.  Parasitic  cysts. 

1.  Echinococcus. 

2.  Cysticercus  cellulosse. 
VII.  Dermoids. 

VIII.  Traumatic  inclusion. 

Retention  Cysts. — A  retention  cyst  is  one  which  forms  in 
consequence  of  obstruction  to  the  outflow  of  secretions  or  other 
body  fluids  and  their  consequent  accumulation  and  distention  of 
the  ducts  or  glands. 

Cause. — The  cause  of  such  obstruction  may  be  very  varied, 
one  or  more  causes  pertaining  to  one  type  of  cyst,  while  another 
type  may  be  produced  by  very  different  causes.  The  usual  ob- 
structions are  cicatrices  or  strictures,  foreign  bodies,  such  as  cal- 
culi in  the  lumen  of  the  duct,  tumors  pressing  upon  and  collapsing 
the  duct  or  invading  and  blocking  it,  and  torsion  of  the  duct. 

Sebaceous  Cysts. — Sebaceous  cysts,  or  atheromata,  are  due 
to  the  blockage  of  the  sebaceous  glands  of  the  skin,  and  con- 
sequently do  not  occur  on  those  surfaces  of  the  body  which  have 
•aceous  glands,  namely,  on  the  palm-  and  soles.  They  may 
occur  on  any  other  part  of  the  cutaneous  surface,  but  are  far 
more  frequently  found  on  the  f:ice,  scalp,  neck,  shoulders,  back,  and 
scrotum.  They  are  produced  l>y  the  formation  of  comedone.-  in 
the  mouth-  of  the  irlands  or  l>y  cicat ri/at  ion  at  the  mouth  of  a  seba- 
ceou>  ulaiid:  the  former  i>  the  more  frequent  cause.  Paradoxically 


634 


PRINCIPLES   OF   SURGERY 


the  site  of  most  common  formation  of  comedones  is  rarely  affected 
by  sebaceous  cysts,  owing  to  the  dense  connective  tissue  in  which 
the  glands  lie. 

The  contents  of  sebaceous  cysts  are  a  dirty,  grayish-looking, 
caseous  residue  of  the  secreted  sebum.  Sometimes  the  employ- 
ment of  pressure  will  dislodge  the  comedo  and  allow  the  evacuation 
of  the  cyst  contents  through  the  mouth  of  the  gland  hi  a  worm- 
like  thread.  Sebaceous  cysts  may  be  single  or  multiple,  occa- 
sionally numerous.  They  are  usually  small,  although  one  occa- 
sionally sees  one  the  size  of  a  hen's  egg,  rarely  as  large  as  a  tan- 
gerine orange.  They  grow  rather  in  a  spheric  shape  when  large, 


Fig.  213. — Cyst  occurring  in  tongue  of  a  woman. 

but  the  smaller  ones  may  be  either  spheric  or  of  a  flattened  saucer 
shape.  They  have  a  boggy  feel,  the  larger  ones  often  being 
pseudofluctuant.  They  originate  in  the  skin,  and,  while  they 
are  distinctly  movable  over  the  remainder  of  their  surface,  a  point 
of  attachment  can  usually  be  discovered.  Their  surface  is  smooth 
and  they  are  elevated,  tumor-like,  above  the  surrounding  skin 
level.  In  the  scrotum  the  coverings  may  be  so  thin  as  to  show 
the  whiteness  of  the  contents  distinctly. 

Sebaceous  cysts  cause  no  pain  and  do  not  endanger  life.  They 
sometimes  become  inflamed  and  may  suppurate,  resembling  some- 
what an  acute  furuncle,  from  which  they  can  be  distinguished  by 


CYSTS  635 

the  comedo,  the  history  of  a  swelling  prior  to  the  appearance  of  in- 
flammation, by  the  contents  of  pus  and  caseous  material,  and  by 
the  absence  of  a  core.  When  inflamed  cysts  are  treated  as  an 
abscess  they  recur,  unless  the  inflammatory  process  has  been 
severe  enough  to  destroy  the  lining  of  the  sac. 

Treatment. — Sebaceous  cysts  are  treated  by  total  excision  of 
the  sac,  preferably  without  opening  it.  If  the  sac  is  accidentally 
opened  the  utmost  care  should  be  employed  to  remove  every 
vestige  of  it  to  prevent  return  of  the  cyst.  Expulsion  of  the 
contents  is  a  worthless  procedure.  If  for  any  reason  the  sac 
cannot  be  dissected  out,  or  if  it  is  deemed  advisable  not  to  at- 
tempt dissection,  the  lining  should  be  thoroughly  cauterized  with 
pure  carbolic  acid  or  otherwise,  packed,  and  allowed  to  heal  from 
the  bottom. 

Mucous  Cysts. — Mucous  cysts  sustain  the  same  relation  to  the 
mucous  glands  that  sebaceous  cysts  do  to  the  sebaceous  glands. 
Mucous  cysts  occur  as  a  consequence  of  blockage  or  obliteration 
of  the  mouths  of  the  glands  by  cicatrices.  They  are  found  espe- 
cially in  the  lining  of  the  mouth  and  on  the  tongue,  occasionally 
they  appear  in  the  vagina;  Nabothian  cysts  are  of  this  type. 
They  are  usually  small,  rarely  attaining  the  size  of  a  chestnut. 
They  are  fluctuant  and  translucent.  Aspiration  procures  a  thin, 
ropy,  mucoid  fluid.  They  may  form  much  more  rapidly  than 
sebaceous  cysts. 

Treatment. — The  treatment  consists  hi  excision,  preferably 
followed  by  suture.  Where  this  is  not  feasible,  the  sac  may  be  slit 
open  and  the  lining  cauterized  or  otherwise  destroyed  and  the 
cavity  allowed  to  heal  from  the  bottom. 

Duct  Cysts. — Among  the  cysts  forming  in  the  glands  or  the 
ducts  affording  an  outlet  to  them  the  usual  ones  are  those  of  the 
salivary  glands,  the  gall-bladder,  the  pancreas,  the  kidneys,  and 
the  vulvovaginal  glands.  In  any  of  these  the  causative  agent  is 
mechanical  obstruction  to  the  duct,  namely,  stones,  scars,  stric- 
tures,  torsion,  tumors  within  or  without  the  duct.  In  the  salivary 
glands  the  common  cause  is  a  stone  within  the  duct  of  the  parotid 
and  of  the  sulmiuxillary  glands.  The  obstruction  of  Rivini's 
ducts,  on  the  contrary,  is  cicatricial.  The  other  possible  causes, 
excepting  torsion,  may  apply  here.  Obstruction  of  Stenson's  duct 
may  cause  cystic  dilatation  of  the  duct  or  of  the  gland;  while  ob- 
struction in  Wharton's  duct  causes  distention  of  the  submaxillary 
inland  owing  to  the  rigidity  of  the  duct.  Obstruction  to  Rivini's 
ducts  causes  distention  of  the  ducts  and  produces  a  sublingual 
cyst  known  as  ranula. 

Cysts  of  the  parotid  gland,  Stenson's  duct,  and  the  submaxil- 
lary gland  fluctuate  in  sixe  if  the  obstruction  is  incomplete,  becom- 


636  PRINCIPLES   OF   SURGERY 

ing  larger  when  salivary  secretion  is  stimulated  during  the  inges- 
tion  of  food  or  acids.  The  recognition  of  these  cysts  is  easy  when 
the  anatomic  site  of  the  structures  containing  them  is  consid- 
ered. They  have  the  usual  characteristics  of  cysts.  In  Stenson's 
and  Wharton's  ducts  the  site  and  often  the  nature  of  the  obstruc- 
tion can  be  determined  by  probing  the  duct,  while  a  ranula  ap- 
pears as  a  round  translucent  sublingual  mass.  Sometimes  when  a 
calculus  causes  the  obstruction  to  Stenson's  or  Wharton's  duct,  it 
can  be  palpated.  Naturally  no  discharge  escapes  from  the  mouth 
of  the  completely  obstructed  duct. 

Treatment. — Treatment  consists  in  the  removal  of  the  obstruc- 
tion if  possible.  If  a  stone  is  present  it  may  be  gradually  forced 
down  to  the  opening  into  the  mouth  and  removed  by  slitting  the 
mouth  of  the  duct,  if  necessary,  or  by  incision  of  the  duct.  Stric- 
tures may  be  dilated  by  the  usual  method  unless  they  are  densely 
closed.  If  the  duct  cannot  be  reopened,  a  new  opening  must  be 
established  with  or  without  excision  of  the  cyst.  In  no  instance 
should  the  mistake  be  made  of  opening  such  a  cyst  (especially  of 
Stenson's  duct)  from  the  skin  surface,  as  it  will  establish  a  very 
annoying  fistula.  This  new  opening  may  be  made  according  to 
Agnew's  plan,  if  the  cyst  is  close  enough  to  the  mucous  lining  of 
the  mouth,  by  transplanting  the  duct  and  making  a  shorter  route, 
or  by  doing  a  plastic  operation  for  reconstruction  of  the  duct. 
When  these  plans  fail  the  only  hope  lies  hi  excision  of  the  gland. 
A  cystic  submaxillary  gland  offers  only  the  alternatives  of  remov- 
ing the  obstruction  and  excision  of  the  gland. 

Ranula  is  treated  by  preference  by  Agnew's  plan.  A  needle 
threaded  with  coarse  linen  or  silk  is  passed  from  the  mucous  mem- 
brane of  the  mouth  into  the  cyst  cavity  and  out  again  and  tied 
loosely.  This  ligature  gradually  cuts  its  way  out  and  re-establishes 
the  opening.  If  this  plan  fails,  the  button-hole  operation  may  be 
done.  As  a  last  resort  excision  of  the  gland  and  cyst  is  done. 

Hydronephrosis  is  usually  caused  by  stone  in  the  ureter,  by 
kinking  or  torsion  of  the  ureter,  or  by  accidental  ligation.  Other 
causes  sometimes  produce  it. 

The  treatment  of  hydronephrosis  demands  removal  of  the 
cause,  nephrotomy  if  a  stone  in  the  ureter,  fixation  of  the  kidney 
if  torsion  is  the  cause,  or  nephrectomy  if  the  kidney  is  hopelessly 
damaged. 

The  remaining  types  of  cystic  kidney  will  be  discussed  in  con- 
nection with  cysts  of  new  formation. 

Cystic  gall-bladder  is  generally  produced  by  blockage  of  the 
cystic  duct  by  gall-stones  or  by  cancerous  obstruction  of  the 
cystic  or  the  common  duct.  In  the  event  that  the  cystic  duct  is 
blocked  the  fluid  is  usually  clear,  with  the  possibility  of  an  admix- 


CYSTS  637 

ture  of  bile;  if  the  common  duct  is  obstructed  bile  may  fill  the 
distended  gall-bladder.  Cystic  gall-bladder  may  be  relieved  by 
removal  of  the* obstruction  or  by  excision  of  the  gall-bladder,  de- 
pendent upon  the  site  and  nature  of  the  obstruction. 

Obstruction  to  the  pancreatic  ducts  is  due  to  stones,  tumors, 
cicatrices.  Pancreatic  cysts  of  the  retention  type  contain  pan- 
creatic fluid.  It  must  not  be  imagined  that  pancreatic  cysts  are  all 
of  the  retention  type.  Others  of  obscure  origin  are  found. 

Pancreatic  cysts  are  treated  by  excision  or  by  marsupialization 
and  drainage.  Fistula  are  likely  to  persist  for  a  long  time  after  the 
latter  plan.  In  cases  of  cure  the  unfortunate  sequela  of  diabetes 
mellitus  has  sometimes  been  observed. 

Cysts  of  the  vulvovaginal  glands  follow  usually  upon  suppura- 
tive  processes  in  them,  which,  in  their  turn,  are  commonly  due  to 
gonorrhea. 

The  treatment  is  excision  and  suture,  or  by  the  open  method. 

Chalazion  is  a  retention,  cyst  of  the  Meibomian  glands,  and 
appears  as  a  small  round  pea-like  body  in  the  upper  eyelid.  They 
are  often  multiple. 

The  treatment  consists  in  eversion  of  the  lid,  incision  through 
the  mucous  membrane  into  the  cyst  in  a  line  parallel  to  the 
normal  direction  of  the  Meibomian  glands,  and  thorough  curet- 
tage  of  the  lining  membrane,  which  must  be  completely  destroyed 
to  prevent  recurrence. 

Retention  cysts  of  the  breast  are  of  several  forms: 

First,  a  chronic  mastitis  may  result  in  the  formation  of  in- 
numerable small  cysts  hi  one  or  both  breasts  and  cause  marked 
enlargement  of  the  organ.  The  condition  is  known  as  cystic  dis- 
ease of  the  breast.  The  cysts  are  small,  averaging  about  the  size 
of  a  pea. 

The  second  form  is  that  in  which  a  tumor  has  formed,  blocked 
the  outlet,  and  caused  the  dilatation  of  a  milk-duct.  The  tumor 
may  be  found  within  the  cavity  of  the  cyst.  The  tumor,  therefore, 
appears  a-  an  intracanalicular  growth. 

The  third  form  of  retention  cyst  of  the  breast  is  the  involution 
cyst.  The  cysts  are  usually  multiple,  of  small  size,  and  filled 
with  fluid  which  may  resemble  milk,  or  be  of  a  serous  or  colloid 
appearance.  It  is  often  brownish  or  greenish  in  color,  and  rarely 
is  caseous. 

Obstruction  to  the  outflow  of  milk  may  result  in  large  cysts 
which  are  termed  galactocele. 

The  treatment  of  retention  cysts  of  the  breast  is  either  excision 
of  the  cyst  or,  if  they  are  numerous  and  cause  annoyance  or  dis- 
figurement, amputation  of  the  breast. 

Lymphatic  and  Chyle  Cysts. — These  cysts  are  of  questionable 


638  PRINCIPLES   OF   SURGERY 

origin,  and  might  perhaps  more  appropriately,  so  far  as  their 
origin  is  concerned,  be  discussed  in  connection  with  lymphan- 
giomata  or,  better  still,  be  described  as  an  ultimate  outcome  of 
lymphangiectases.  The  fact  remains,  however,  that  they  obtain 
their  origin  as  cysts  by  the  retention  of  the  lymph  in  the  dilated 
lymphatics,  and  as  the  distention  continues  all  avenues  of  entrance 
and  exit  from  the  cystic  cavity  are  closed  and  the  lining  endothe- 
lial  cells  assume  a  secretive  action.  They  are  most  common  in 
the  neck,  where  they  are  known  as  congenital  cystic  hygroma,  and 
appear  as  moderate  or  enormous  enlargements  hi  the  newborn 
and  show  the  common  characteristics  of  cysts.  They  are  trans- 
lucent if  the  fluid  is  clear  serum;  but  it  may  be  milky  or  chocolate 
colored,  and  translucency  is  wanting  in  these.  They  are  multi- 
locular  cysts  and  often  extend  down  among  the  structures  of  the 


Fig.  214. — Large  hydrocele  in  tunic,  the  neck  of  which  was  unobliterated. 
The  constriction  at  the  left  lay  within  the  deep  ring. 

neck,  so  that  removal  in  toto  is  out  of  the  question.  These  cysts 
may  disappear  spontaneously  as  the  child  develops,  or  may  require 
dissection,  which  gives  satisfactory  results  even  when  the  whole 
cyst  cannot  be  removed. 

Similar  cysts  appear  hi  the  mesentery  and  contain  chyle,  and 
are  known  as  mesenteric  chyle  cysts.  They  are  not  congenital  in 
origin  and  probably  result  from  obstructions  occurring  at  the  time 
of  their  origin.  Such  cysts  have  rarely  been  reported  as  inter- 
fering with  delivery  of  pregnant  women. 

The  treatment  is  removal,  complete  or  partial,  as  circum- 
stances demand. 

A  retention  cyst  known  as  spermatocele  forms  in  the  epididy- 
mis  and  may  reach  the  size  of  an  orange.  It  contains  semen  or 
altered  semen,  and  is  lined  with  ciliated  epithelium. 

Treatment  is  enucleation. 


CYSTS  639 

Exudation  Cysts. — This  group  of  cysts  forms  in  pre-existing 
closed  cavities  lined  with  endothelium  and  capable  of  a  normal 
secretory  function.  The  action  of  traumatism,  irritation,  and  in- 
flammation may  cause  an  increase  hi  the  quantity  of  the  secre- 
tion, which,  if  it  is  maintained,  results  hi  the  formation  of  exuda- 
tion cysts. 

The  form  of  exudation  cyst  by  far  the  most  common  is  hydro- 
cele, an  accumulation  of  fluid  hi  the  tunica  vaginalis  testis.  The 
fluid  is  sometimes  discolored  to  a  reddish  or  brownish  color  or 
contains  blood  hi  old  cases  of  hydrocele  with  large  sacs.  The  sac 
itself  is  usually  the  distended  tunic,  a  simple  sac.  If  a  plastic 
inflammation  preceded  the  hydrocele,  however,  the  parietal  and 
visceral  tunics  may  have  adhered,  and  the  distention  resulting 
from  the  accumulating  fluid  produce  septa  which  divide  the 
cavity  more  or  less  completely  into  compartments.  The  shape 
of  the  mass,  being  larger  above  than  below,  fluctuation,  the 


Fig.  215. — Small  exudation  cyst  of  index-finger. 

history  of  the  cause,  translucency  and  the  recovery  of  fluid  on 
as  pi  ration  are  the  chief  diagnostic  features.  The  quantity  of  fluid 
may  be  as  much  as  a  quart.  Similarly,  but  much  less  frequently, 
a  hydrocele  may  form  in  the  canal  of  Nuck  in  females. 

Treatment. — The  treatment  of  hydrocele  is  palliative  or  cura- 
tive. The  former  plan  simply  contemplates  temporary  relief  from 
the  dragging  weight  by  aspiration.  Curative  treatment  contem- 
plates destruction  of  the  lining  secreting  endothelium  or  removal 
of  the  sac.  This  may  be  done  by  the  injection  of  30  to  60  minims 
of  pure  carbolic  acid  after  withdrawal  of  the  fluid,  followed  imme- 
diately by  massage  to  bring  the  acid  into  contact  with  the  whole 
lining,  after  \\hirh  it  is  to  be  washed  out  with  normal  salt  solution 
to  prevent  necrosis  or  systemic  poisoning.  If  the  fluid  reaccumu- 
lates,  as  it  often  does,  it  should  !><•  aspirated  again  at  the  end  of  a 
week.  This  method  cures  about  90  per  cent,  of  the  cases  when 
properly  done,  but  fails  in  the  long-standing  cases  of  hydrocele 


640  PRINCIPLES   OF   SURGERY 

with  a  thick  sac.  In  the  second  plan  (Volkmann),  one  buttonholes 
the  sac  and  sutures  the  skin  to  the  serous  membrane.  The  cavity 
is  then  packed  with  gauze  and  caused  to  heal  from  the  bottom. 
The  third  plan  (Jaboulay)  slits  the  sac  and  turns  it  inside  out, 
placing  the  endothelial  cells  in  contact  with  the  raw  inner  surface 
of  the  scrotum.  The  sac  may  be  completely  cut  away  if  neces- 
sary (von  Bergmann). 

The  exudation  cysts  second  in  frequency  are  those  that  form  hi 
the  various  bursse  of  the  body.  Their  'position  and  the  common 
characteristics  of  a  cyst  are  sufficient  to  distinguish  them  from  other 
lesions. 

Four  exudation  cysts  deserve  especial  mention,  inasmuch  as 
they  have  received  special  names.  They  are  as  follows: 

Miners'  elbow  is  an  exudation  cyst  which  forms  in  the  bursse 
overlying  the  olecranon  process  in  consequence  of  the  repeated 
traumatism  to  the  elbow  of  miners.  Housemaids'  knee  is  an 
exudation  cyst  of  the  prepatellar  bursse.  It  obtains  the  name  from 
its  frequent  occurrence  in  housemaids,  whose  occupation,  as 
originally  followed,  caused  irritation  of  this  bursa.  Weavers' 
bottom  is  a  third  example  of  this  cyst,  which  is  produced  by 
occupation;  it  forms  over  the  tuber  ischii.  Boyer's  cyst  is  an 
exudation  cyst  of  the  subhyoid  bursa. 

Treatment. — The  treatment  of  exudation  cysts  consists  in  either 
removal  of  the  sac  in  toto,  or,  if  this  is  impossible,  destruction  of 
the  lining  by  the  methods  already  mentioned  in  connection  with 
hydrocele. 

Hydrothorax  and  ascites  are  pathologically  identical  with 
exudation  cysts,  but  are  not  so  classed  in  the  literature. 

Extravasation  Cysts. — This  group  of  cysts  depends  for  its 
existence  upon  the  fact  that  they  are  due  to  the  escape  of  blood 
into  the  space  they  occupy.  They  may,  therefore,  be  of  the  reten- 
tion or  the  exudation  type  or  may  be  cysts  of  new  formation; 
in  the  latter  instance  the  sac  forms  about  the  extravasated  blood. 

Occasionally  numerous  exudation  cysts  form  in  the  vesicles  of 
the  thyroid  gland,  constituting  one  form  of  cystic  goiter.  The 
ovaries  may  also  be  the  site  of  similar  cysts,  of  which  there  are  two 
types,  namely,  cysts  of  the  corpora  lutea  and  cysts  of  the  Graaffian 
follicles.  The  former  really  belongs  to  the  hemorrhagic  cysts. 
The  Graaffian  follicular  cysts  are  multiple,  small,  and  harmless. 

Embryonal  Cysts. — This  group  depends  upon  the  presence  of 
unobliterated  fetal  spaces  or  canals,  which  remain  as  persistent 
parts  in  the  fully  developed  individual.  These  spaces  were  origin- 
ally lined  with  epithelium,  consequently  the  cysts  have  normally 
a  cellular  lining.  The  most  important  of  this  group  are  the 
thyroglossal  cysts,  branchial  cysts,  cysts  of  the  urachus,  hydrocele 


CYSTS  641 

of  the  cord,  non-traumatic  (fetal)  inclusion  cysts,  cysts  of  the 
\\  "Iff inn  bodies,  and  vitello-intestinal  cysts. 

Thyroglossal  cysts  occur  in  the  unobliterated  portion  of  the 
thyroglossal  or  thyrolingual  duct.  They  appear  in  the  median 
line  of  the  neck  anteriorly  above  the  thyroid  gland  and  below  the 
foramen  cecum.  Branchial  cysts  are  due  to  cystic  destruction 
of  unobliterated  branchial  clefts,  forming  only  in  the  second  and 
last  cleft ;  they  may  form  laterally  under  the  tongue,  or  in  the  neck 
at  any  point  from  the  angle  of  the  jaw  to  the  sternum.  These  cysts 
contain  a  fluid  or  caseous  material.  When  the  content  is  fluid, 
it  i-  due  to  the  derivation  of  the  cyst  from  the  inner  or  mucous  end 
of  the  cleft,  and  is  mucoid.  When  the  outer  or  cutaneous  end 
produces  the  secretion,  it  is  caseous.  These  cysts  give  rise  to  no 
little  trouble  from  a  diagnostic  standpoint  and  can  be  recognized 
oft«-n  only  by  eliminating  other  swellings  of  the  neck.  If  they  are 
opened  they  give  rise  to  persistent  and  troublesome  fistulas. 

Cysts  of  the  urachus  are  extremely  rare.  They  appear  in  the 
anterior  wall  of  the  abdomen — i.  e.,  anterior  to  the  peritoneum — 
and  may  reach  an  enormous  size.  They  must  be  distinguished 
from  distended  bladder  and  all  forms  of  cysts  occurring  in  the 
lower  half  of  the  abdomen. 

Hydrocele  of  the  cord  is  produced  by  causes  similar  to  those 
producing  true  hydrocele  in  a  peritoneal  pouch  which  has  failed 
to  be  obliterated;  closure  occurs  above  and  below,  the  sac  remains 
between. 

Sequestration  cysts  are  formed  in  consequence  of  fetal  mal- 
development  in  which  portioas  of  the  skin  are  separated  and  en- 
clo-ed  in  the  subcutaneous  structures.  They  usually  lie  super- 
ficially, but  may  be  buried  rather  deeply  in  the  tissues.  These 
cysts  occur  in  the  median  line  of  the  body  and  at  the  points  where 
the  fetal  clefts  exist.  They  are  lined  with  true  skin,  which  often 
contain-  hairs  attached  or  detached,  and  are  filled  with  either  a 
ea.-eou-  -ul'-tancr  or  a  viscid  fluid.  Sequestration  cysts  are  found 
most  frequently  in  the  region  overlying  the  coccyx,  where  one 
may  often  discover  blind  pockets  leading  upward  beneath  the 
skin.  These  not  infrequently  lead  into  a  sequestration  cyst,  which, 
if  it  become-  inflamed  or  discharges  fluids  from  the  opening,  is 
sometime-  mistaken  for  fistula  in  ano,  unless  a  careful  examina- 
tion !*•  made. 

( 'y-t>  forming  in  the  remains  of  the  fetal  urogenital  apparatus 
are  rather  frequent.  They  may  form  in  the  Wolff ian  l>o.ly,  the 
organ  of  l\o-enmiiller.  or  in  (iartner'-  duct.  Those  which  develop 
in  the  outer  tube-  of  the  organ  of  Koseiimuller  are,  as  a  rule,  small 
and  give  rise  to  no  disturbance.  a\\  the  other  hand,  enormous 
cy.-t-  may  form  from  the  vertical  tubes.  ( 'y-t-  of  the  Wollfian  body 

41 


642  PRINCIPLES   OF   SURGERY 

often  contain  papillomata.  They  are  usually  multilocular  and 
tend  to  extend  downward  in  the  broad  ligament.  They  occur 
usually  in  adults.  These  cysts  all  form  in  the  broad  ligament  or  in 
connection  with  it.  The  cysts  which  arise  from  Gartner's  duct 
occur  either  in  the  broad  ligament  between  the  ovary  and  the 
uterus  and  produce  only  small  cysts,  or  hi  the  vaginal  wall  laterally, 
and  here  are  usually  solitary  and  small,  or  they  may  be  multiple 
and  arranged  in  chains. 

Vitello-intestinal  cysts  are  found  at  the  navel,  where  they  may 
appear  as  a  mass,  project  outward,  or  be  concealed  beneath  the 
abdominal  wall  as  extraperitoneal  cysts.  They  form  in  the  un- 
obliterated  remains  of  the  omphalomesenteric  duct. 

Congenital  cystic  kidney  is  a  very  interesting  pathologic  lesion. 
The  kidneys  of  the  fetus  may  be  so  large  at  birth  as  to  interfere 
materially  with  labor,  or  produce  death  of  the  baby  soon  after 
labor.  In  other  instances  they  are  only  discovered  after  the  patient 
has  reached  the  adult  state.  It  is  a  bilateral  condition,  a  fact  to 
be  remembered  when  surgical  treatment  is  contemplated.  The 
kidneys  are  made  up  of  innumerable  cysts  of  varying  sizes,  and  the 
condition  is  thought  to  be  due  to  an  arrest  of  development  during 
the  fetal  state.  The  kidneys  may  attain  the  enormous  size  of  a 
child's  head  in  extreme  cases.  Patients  who  have  congenital  cystic 
kidneys  may  occasionally  live  to  be  old  and  die  suddenly  of 
uremia.  The  condition  is  often  associated  with  a  cystic  liver  and 
rarely  also  with  a  cystic  pancreas. 

Cholesteatoma  is  classified  by  some  authors  as  an  endothelial 
tumor,  by  others  as  a  form  of  cyst  originating  from  cells  which 
have  been  displaced  from  their  cutaneous  attachments  during 
development,  by  invasion  of  epithelial  cells  into  unnatural  posi- 
tions during  disease,  as  occurs  hi  extension  of  the  skin  cells  into  the 
tympanic  cavity  following  otitis,  or  by  metaplasia  of  the  cells. 
Structurally  and  developmentally  cholesteatoma  is  unquestionably 
a  cyst.  The  cyst  wall  is  a  fibrous  capsule  lined  with  stratified 
epithelium,  and  in  rare  instances,  even  when  in  the  pia,  may  con- 
tain hair,  together  with  sebaceous  and  sweat-glands.  The  contents 
consist  of  a  solid  pearly  gray  or  white  substance  containing  large 
quantities  of  fatty  substances  and  cholesterin.  Cholesteatomata 
are  small,  rarely  becoming  larger  than  a  Japanese  plum,  but  by 
virtue  of  their  predilection  for  the  temporal  bone,  especially  the 
middle  ear,  the  mastoid,  and  the  pia  mater,  may  cause  grave  symp- 
toms from  pressure.  They  grow  slowly,  but  when  they  are  situ- 
ated within  bone  cause  atrophy  or  necrosis,  rupturing,  for  in- 
stance, from  the  mastoid  either  toward  the  scalp  or  the  dura. 
They  are  occasionally  found  hi  the  urethra. 

Treatment. — The  treatment  for  all  the  group  of  embryonal 


CYSTS  643 

cysts  consists  in  removal,  with  the  exception  of  those  appearing  in 
the  liver  and  the  kidneys,  where  radical  procedures  are  contra- 
indicated. 

Dentigerous  Cysts. — Numerous  maldevelopments  occur  in 
connection  with  the  teeth,  which  pass  under  the  name  of  odonto- 
mata  and  dentigerous  cysts.  Both  conditions  are  due  to  per- 
verted development  of  the  teeth  or  the  structures  entering  into 
their  formation.  Odontomata  in  the  vast  majority  of  cases  are 
not  true  tumors,  as  their  name  would  imply,  hence  the  failure  to 
discuss  them  hi  connection  with  tumors.  It  is,  practically,  unwise 
to  separate  odontomata  from  dentigerous  cysts;  therefore  a  brief 
discussion  of  both  conditions  will  be  given  hi  this  connection. 

Bland-Sutton's  classification  of  odontomata  is  as  follows: 
"1.  Epithelial  odontoma,  from  the  enamel  organ. 

2.  Follicular  odontoma,  ^ 

3.  Fibrous  odontoma,  1  from  the  tooth- 

4.  Cementoma,  |      follicle. 

5.  Compound  follicular  odontoma,  J 

6.  Radicular  odontoma,  from  the  papilla. 

7.  Composite  odontoma,  from  the  whole  germ." 
Epithelial  odontomata  arise  from  the  enamel  organ  and  develop 

as  small  tumors  in  connection  with  the  gum  of  the  lower  jaw, 
rarely  of  the  upper,  of  individuals  past  middle  life.  They  are  rarely 
larger  than  a  large  hazelnut.  They  are  structurally  multilocular 
cysts  whose  septa  are  fibrous  or  perhaps  ossified.  Bland-Sutton 
asserts  that  many  of  these  cysts  are,  hi  reality,  endotheliomata. 

Follicular  odontomata  constitute  the  real  cystic  odontomata  or 
(Icntigerous  cysts.  They  are  ensheathed  by  a  capsule  whose  thick- 
ness varies  from  that  of  parchment  to  }  inch  or  more.  This  mem- 
brane  is  the  outgrowth  or  overgrowth  of  the  tooth-follicle.  The 
cavity  contains  a  mucoid  ropy  fluid  and  the  tooth  or  the  remains 
of  one  whose  eruption  failed  to  occur.  Occasionally  the  tooth 
entirely  fails  to  develop.  These  cysts  arise  in  either  the  upper  or 
the  lower  jaw  and  may  be  bilateral.  They  usually  arise  from  the 
permanent  tooth-follicles,  and  among  these  more  frequently  from 
the  molars,  rarely  from  supernumerary  teeth.  The  presence  of  a 
tumor,  the  absence  of  a  tooth  which  has  failed  to  erupt,  the  benign 
behavior  of  the  growth,  the  presence  of  fluid  obtainable  on  aspira- 
tion, and  the  <li-covery  of  the  tooth  within  the  sac  by  puncture 
with  a  steel  needle  confirm  the  diagnosis.  Follicular  cysts  are 
likely  to  be  mistaken  for  sarcomata,  but  this  should  not  lead  to 
serious  errors  now  as  it  has  done  in  the  past,  for  no  surgeon  who 
car.  -  for  his  reputation  or  his  patient  operates  now-a-days  for  a 
malignant  growth,  so  long  as  there  i-  a  possibility  of  error,  without 
first  having  a  microscopic  examination.  In  cases  where  the  cyst 


644  PRINCIPLES   OF   SURGERY 

arises  from  supernumerary  teeth,  of  course,  no  evidence  of  a  missing 
tooth  is  at  hand.  In  the  majority  of  cases,  in  all,  in  fact,  except 
where  no  tooth  structure  is  present  within  the  cyst,  a  skiagraph 
should  reveal  the  true  condition  of  affairs.  The  tooth  contained 
in  the  sac  has  imperfectly  developed,  short,  stumpy  roots. 

Fibrous  odontomata  are  derived  from  the  tooth-follicle  by  the 
production  of  a  large  amount  of  connective  tissue  surrounding  the 
tooth.  They  are  very  likely  to  be  mistaken  for  fibromata,  until 
the  absence  of  a  normal  tooth  is  observed  and  its  presence  within 
the  mass  ascertained. 

If  cement  is  desposited  in  the  fibrous  portion  of  a  fibrous 
odontoma  it  becomes  solid  and  rock-like,  and  is  known  as  a 
cementoma. 

Partial  deposits  of  cement  or  formation  of  dentin  in  the  fibrous 
portion  of  a  fibrous  odontoma  causes  the  mass  to  yield  numerous 
solid  bodies  resembling  teeth  more  or  less  completely,  and  made 
up  of  one  or  all  the  elements  which  constitute  normal  teeth. 
This  is  known  as  compound  follicular  odontoma. 

Radicular  odontomata  are  due  to  the  o'vergrowth  of  the  root 
of  a  tooth  after  the  crown  is  fully  formed.  They  do  not  contain 
cementum. 

When  the  three  elements  of  tooth  structure — dentin,  cement,  and 
enamel — grow  into  a  bony  mass,  the  resultant  tumor  is  a  com- 
posite odontoma,  which  often  originates  from  the  formative  struc- 
tures of  more  than  one  tooth.  It  is  a  rough,  hard,  irregular  bony 
mass,  occurring  either  in  the  upper  or  the  lower  jaw,  especially 
the  latter,  in  which  it  may  attain  considerable  size.  It  is  rare. 

Treatment. — The  treatment  of  odontomata  consists  in  removal 
of  the  pathologic  tissue.  It  is  unnecessary  to  resect  the  jaw  for 
them,  but  if  they  are  large  it  may  be  necessary  to  do  extensive 
removal  of  the  deformed  portions  of  bone  in  order  to  obtain  a 
shapely  jaw. 

Cysts  of  New  Formation. — The  cysts  of  new  formation  not 
due  to  parasites  are  of  only  moderately  frequent  occurrence,  if  we 
except  those  that  appear  in  connection  with  tumors.  They  are 
found  hi  the  soft  parts  and  in  bone.  Cysts  of  new  formation  are 
due  to  hemorrhage,  tumors,  or  necrosis. 

Hemorrhagic  Cysts. — It  is  the  rule  that  when  hemorrhage 
occurs  into  the  tissues  of  the  body  a  hematoma  remains  for  a  time 
and  gradually  disappears  by  absorption,  leaving  no  evidence  of 
its  former  presence  except  a  slight  amount  of  scar  tissue.  This 
rule  has  exceptions:  the  blood  may  remain  unabsorbed  and  a  sac 
gradually  develop  around  it,  so  that  it  becomes  a  permanent  lesion. 
The  blood-cells,  the  hemoglobin,  and  whatever  of  necrotic  tissue 
may  be  present  are  removed  and  there  remains  only  a  clear  serous 


CYSTS  645 

fluid.  At  first  the  tissues  surrounding  the  cyst  remain  more  or 
less  discolored,  but  this  discoloration  finally  disappears  and  leaves 
no  sign  to  indicate  the  true  source  of  the  cyst.  Naturally,  these 
cysts  are  largely,  though  not  entirely,  due  to  traumatism.  Hemor- 
rhagic  cysts  are  found  in  goiters,  hi  the  brain,  the  scalp  of  the 
newborn,  where  they  are  known  as  cephalematomata,  "hi  the 
pinnae  of  football  players  and  lunatics"  (othematoma),  and  rarely 
in  the  spleen. 

In  the  neck  a  type  of  blood-cyst  is  occasionally  found  which  is 
not  due  to  hemorrhage.  They  may  attain  an  enormous  size,  that 
of  a  child's  head.  They  may  be  connected  with  the  veins  of  the 
neck  and  are  then  reducible  hi  size  by  continued  pressure,  or  they 
may  have  no  such  connection  and  be  irreducible.  The  majority 
belong  to  the  latter  class.  They  have  been  attributed  to  cavernous 
angioma,  but  their  origin  is  not  so  well  determined  as  to  explain  all 
MMB. 

Treatment. — The  treatment  of  hemorrhagic  cysts  is  removal. 
If  this  cannot  be  done  the  cyst  may  be  opened  and  cauterized  or 
packed,  or  both,  as  the  case  may  require.  Blood-cysts  which  are 
reducible  should  be  dissected  out  and  removed  after  ligation  of 
their  points  of  connection  with  the  normal  vessels. 

Cysts  hi  bone  are,  aside  from  the  so-called  dentigerous  cysts, 
exceedingly  rare  lesions.  The  majority  of  them  are  due  to  cystic 
degeneration  of  solid  tumors  of  bone,  especially  sarcoma  and 
chondroma,  less  frequently  intra-osseous  fibroma,  and  very 
rarely  metastatic  carcinoma.  Genuine  primary  cysts  do  rarely 
occur;  osteomalacia  and  arthritis  deformans  may  produce  cysts 
in  the  bones.  .  Parasitic  cysts  are  rarely  observed.  The  presence 
of  large  cysts  in  bone  produces  the  same  symptoms  and  signs  that 
are  observed  in  tumors  of  bone.  The  bone  becomes  enlarged  and 
the  wall  may  be  so  thinned  as  to  crepitate.  One  very  important 
fact  to  remember  is  that  since  bone-cysts  are  frequently  due 
to  changes  occurring  in  a  tumor,  it  is  not  sufficient  to  satisfy  one's 
self  with  the  diagnosis  of  cyst;  one  must  determine  microscopically 
whether  the  given  cyst  is  associated  with  sarcoma  cells,  and  the 
treatment  must  be  directed  accordingly. 

The  treatment  of  bone-cysts,  if  they  are  not  sarcomatous, 
is  to  open  the  cyst,  clean  out  the  cavity,  curet  or  cauterize,  and 
clo<e  the  wound.  If  the  bone  is  extensively  destroyed,  resection 
or  amputation  may  be  necessary. 

Cystic  Tumors. — Of  this  group  some  give  the  impression  that 
the  lesion  is  a  tumor  and  the  cystic  portion  a  secondary  matter; 
others  an-  so  typically  cystic  that  their  origin  from  a  previous 
tumor  would  never  l>e  suspected  from  a  clinical  examination  of  the 
patient  or  by  the  most  careful  investigation  of  the  gro<-  -p< •< -mien. 


646 


PRINCIPLES   OF   SURGERY 


They  may  be  subdivided  into  two  groups,  namely,  those  which 
result  from,  the  action  of  the  cells  lining  a  tumor  which  has  a  real 
or  a  virtual  cavity,  cystadenomata,  and  those  due  to  degenerative 
changes,  found  most  typically  in  sarcomata,  but  also  in  fibro- 
mata, chondromata,  and  carcinomata.  It  sometimes  happens  that 
a  hemorrhagic  cyst  develops  in  a  soft  tumor,  just  as  it  does  hi 
normal  structures. 

Cystadenoma. — This  is  one  of  the  most  frequent  forms  of  cyst, 
and,  though  it  may  develop  hi  various  structures  which  produce 


Fig.  216. — Simple  cyst  of  spleen. 

adenomata,  is  observed  with  greatest  frequency  in  the  breast  and 
the  ovary.  If  the  cells  of  the  tumor  secrete  a  fluid  the  latter  ac- 
cumulates and  distends  the  cavity. 

Cystadenomata  of  the  ovary  are  frequent;  they  are  unilateral 
or  bilateral,  unilocular  or  multilocular.  They  usually  develop  in 
adults,  but  are  occasionally  seen  in  children.  Their  size  is  ex- 
ceedingly variable  and  they  continue  often  to  grow  until  it  would 
seem  the  patient  was  attached  to  the  tumor.  It  is  quite  common 
to  find  such  a  cyst  containing  5  to  7  gallons  of  fluid,  and  occasional 


CYSTS 


647 


specimens  are  reported  as  weighing  100  pounds  or  more.  The 
enormous  mass  in  the  abdomen  necessarily  causes  great  and 
increasing  distress  from  pressure  not  only  upon  the  abdominal 
vi-cera,  but  the  thoracic  as  well.  There  are  two  forms  of  cyst- 
adenoma  of  the  ovary,  the  simple  form  and  cystadenoma  papil- 
liferum. 

Cystadenoma  of  the  breast  is  another  frequent  form,  although 
it  must  be  stated  that  the  majority  of  mammary  cysts  are  of  the. 
retention  type.     They  may  be  single  or  multiple,  usually  the 
former,  and  quite  frequently  are  bilateral. 


Fig.  217.— Ovarian  cyst  measuring  nearly  2  feet  fn  its  long  diameter. 

Cystic  -arcomata  have  been  sufficiently  discussed  under 
Sarcoma. 

Treatment. — The  treat  incut  of  cystic  tumors  is  removal. 
Relief  of  urgent  symptoms  from  cyst  adenoma  of  the  ovary  may  be 
attained  temporarily  by  aspiration,  but  this  plan  should  never  be 
n  -niied  to  unless  celiotomy  is  contra-indicated. 

Necrotic  cysts  are  similar,  in  their  manner  of  formation,  to 
hemorrhage  cysts.  In  the  latter  a  blood-clot,  which  is  practi- 
cally dead  ti»ue  or  becomes  so  soon  after  its  escape  from  the 
b|  H  dealt  with  precisely  as  the  non-infected  infarct  or  other 
necrotic  matter  is  in  the  former.  It  is  liquefied,  the  solid  parts  are 


648 


PRINCIPLES   OF   SURGERY 


removed,  and  a  cyst  wall  forms  around  it,  enclosing  the  remaining 
fluids.  This  is  the  type  of  cystic  degeneration  found  in  malignant 
tumors. 


Fig.  218. — Abdomen  prior  to  operation  from  which  the  cysts  shown  in  Fig. 

219  were  removed. 

Parasitic  Cysts. — There  are  two  types  of  parasitic  cyst,  namely, 
that  produced  by  the  dog  tapeworm,  Echinococcus  hydatidosus, 


Fig.  219. — Two  ovarian  cysts  removed  from  case  shown  in  Fig.  218. 

and  that  produced  by  the  Cysticercus  cellulosae,  representing  the 
larval  stage  of  Tsenia  solium  and  producing  the  disease  known  as 
"measles." 


CYSTS  649 

Echinococcus  Hydatidosus. — This  is  the  tapeworm  of  the  dog, 
in  whose  alimentary  tract  it  spends  its  adult  stage.  The  larval 
stage  is  spent  in  another  host,  in  whose  tissues  it  produces  echino- 
coccus  or  hydatid  cysts. 

The  eggs  of  the  tapeworm  form  in  the  last  (fourth)  segment 
and  are  passed  from  the  alimentary  tract  of  the  dog  with  the 
feces.  They  are  then  taken  into  the  human  stomach  in  water,  on 
uncooked  vegetables,  or  more  directly  by  the  filthy  practices  of 
individuals  who  allow  their  dogs  to  lick  their  hands  or  faces. 
Once  the  egg  gains  admission  to  the  stomach,  the  digestive  process 
destroys  the  capsule  and  liberates  the  embryo,  which  attaches 


l-'iu.  '.?•_'< ».  — ( 'yst  ic  t  uhrrmlivr  kidney.    Note  the  large  cyst  above«nd  the  smaller 
one  at  lower  pole  filled  with  caseous  material.     (About  \  natural  size.) 

itself  to  the  lining  of  the  stomach  and  gradually  penetrates  the 
mucous  membrane  and  enters  the  blood-vessels  or  the  lymphatic 
.vessels,  through  which  it  is  carried  more  or  less  remotely  from 
the  stomach  and  lodges.  If  the  blood-vessels  receive  the  embryos 
they  an-  transported  directly  to  the  liver;  if  the  lymphatics,  the 
first  >ct  <»f  capillaries  they  must  pass  are  those  of  the  lungs.  This 
explains  the  frequency  with  which  these  organs  are  affected,  as 
many  of  the  organisms  are  too  large  to  pass  the  narrow  capillary 
lumina. 

Once  the  echinococcus  has  lodged,  it  begins  to  develop  into  a 
cy.-t.  The  embryo  enlarges  into  a  spheric-shaped  cyst  which  has  a 
wall  of  two  layers,  an  outer  euticular  layer  of  lamellated  chitin  and 


650  PRINCIPLES   OF   SURGERY 

an  inner  parenchymatic  or  germinal  layer  of  granular  material. 
Surrounding  the  outer  layer  is  a  fibrous  capsule  such  as  is  thrown 
around  any  foreign  body  in  the  tissues,  such  as,  indeed,  constitutes 
the  sac  of  ordinary  cysts.  The  capsule  contains  a  fluid,  usually 
clear,  of  low  specific  gravity  (1007),  containing  albumin,  and  in  the 
liver  sometimes  sugar;  it  furthermore  contains  the  characteristic 
hooklets  derived  from  the  rostellum  of  the  embryos.  When  the 
fluid  of  the  cyst  is  evacuated  the  parasitic  portion  of  the  wall 
drops  easily  away  from  the  fibrous  sac  afforded  by  the  host  and 
appears  as  a  peculiar  whitish  looking  membrane,  which  will  serve 
to  characterize  the  cyst  even  when  hooklets,  scolices,  or  daughter- 
cysts  cannot  be  found. 

The  cyst  develops  for  two  or  three  months  as  a  simple  cyst 
and  shows  no  contents  except  the  fluid  already  mentioned  (acepha- 
locyst).  By  this  time  it  has  usually  reached  the  size  of  a  guinea- 
hen's  egg.  Then  hollow  processes  develop  in  the  lumen  of  the 
cyst  from  the  germinal  layer,  known  as  brood-capsules;  within 
these  brood-capsules  scolices  form.  These  brood-capsules  may 
become  separated  from  the  mother-cysts  and  lie  in  the  fluid  of  the 
original  cyst,  or  they  may  rupture  and  leave  the  scolices  attached 
to  the  parenchymatic  layer,  or  they  may  become  detached  and 
be  free  in  the  cystic  fluid.  Cysts  known  as  daughter-cysts  may 
form  within  the  original  (mother-cyst)  from  the  separated  brood- 
capsules  or  from  the  separated  scolices  being  converted  into 
cysts.  Even  within  these  secondary  cysts  others  may  form — 
granddaughter-cysts.  The  daughter-  and  granddaughter-cysts 
may  be  only  a  few  or  they  may  reach  into  thousands,  literally 
filling  the  large  mother-cyst. 

Daughter-cysts  occasionally  form  on  the  outside  of  the  brood- 
capsule  and  gradually  escape  from  it,  so  that  a  large  number  of 
cysts  form  side  by  side.  This  is  the  rule  of  formation  of  daughter- 
cysts  in  echinococcus  of  the  osseous  system  and  of  the  species 
known  as  Echinococcus  multilocularis. 

Echinococcus  cysts  are  sometimes  sterile,  containing  no 
daughter-cysts,  no  brood-capsules,  and  no  hooklets. 

Hydatid  cysts  are  more  frequent  naturally  in  those  countries 
whose  inhabitants  associate  habitually  with  dogs.  In  Iceland  it 
is  said  that  one  individual  out  of  every  seven  is  affected.  They  are 
very  frequent  in  Australia  and  in  certain  parts  of  Europe.  In 
America  they  are  rare,  being  most  common  in  Manitoba  and  the 
northwestern  part  of  the  United  States. 

The  organs  especially  affected  are,  as  has  been  already  stated, 
the  liver  and  the  lungs.  Other  structures  less  frequently  involved 
are  the  central  nervous  system,  the  bones,  the  skin,  and  the  peri- 
toneum. Secondary  cysts  may  result  from  rupture.  This  fact  is 


CYSTS  651 

especially  to  be  borne  in  mind  in  cases  submitted  to  aspiration  or 
operation  when  the  original  cyst  lies  within,  or  requires  opening  of, 
the  peritoneal  or  pleural  cavity. 

Diagnosis. — There  are  no  definite  symptoms  referable  to 
echinococcus  cysts.  They  develop  slowly  and  attain  a  moderate 
or  an  enormous  size,  and  kill  their  host  hi  about  one-half  the  cases 
in  five  years.  They  may  grow  intermittently.  They  manifest 
the  same  clinical  signs  found  hi  cysts  in  general,  with  the  addi- 
tional sign  sometimes  described  as  echinococcus  thrill,  or  fremitus, 
elicited  by  cross  palpation.  The  pathognomonic  evidence  is  the 
finding  of  booklets  hi  the  fluid,  the  presence  of  the  sac  with  its 
unique  structure,  or  the  appearance  of  daughter-cysts  or  brood- 
capsules.  They  may  be  single  or  multiple  and  appear  hi  one  or 
many  organs  at  the  same  time. 

Accidents. — The  echinococci  may  die  from  unknown  causes  or 
during  some  intercurrent  disease,  and  the  growth  not  only  be 
checked,  but  actual  cure,  with  absorption  of  the  fluid,  sometimes 
takes  place.  The  solid  remains  may  be  found  hi  the  tissues  hi  the 
form  of  a  calcareous  deposit  hi  the  midst  of  which  the  booklets 
can  be  identified.  This  is  a  fairly  frequent  termination. 

Infection  may  occur  in  echinococcus  cysts  and  produce  the  at- 
tendant signs  and  symptoms  of  inflammation.  The  increased  ten- 
sion is  often  responsible  for  rupture  of  the  cyst  and  escape  of  its 
infested  contents  into  a  serous  cavity  or  blood-vessel,  with  the 
severe  and  fatal  symptoms  which  necessarily  follow  such  an 
accident. 

Rupture  of  echinococcus  cysts  may  occur  spontaneously  or  as 
the  result  of  accident.  This  causes  diffusion  of  the  echinococci 
into  the  surrounding  structures  or  spaces  and  is  followed  by  the 
development  of  new  cysts.  The  peritoneum  or  pleura  may  hi  this 
manner,  or  by  leakage  following  aspiration,  or  by  accidental 
escape  during  operation,  become  literally  filled  with  cysts.  An- 
other result  of  rupture  is  the  appearance  of  urticaria;  this  symptom 
sometimes  follows  aspiration  of  a  hydatid  cyst  and  is  then  con- 
sidered pathognomonic.  Rupture  into  the  peritoneal  cavity  is 
followed  either  liy  insignificant  symptoms  or  by  severe  symptoms 
of  a  toxic  nature,  as  collapse  and  syncope,  which  may  terminate 
in  death.  Peritonitis  may  follow  rupture  into  the  peritoneum. 
Cysts  in  which  the  echinococci  have  died  are  said  to  produce 
the  more  violent  symptoms  when  rupture  into  the  peritoneum 
occurs,  rupture  of  the  living  cysts  causing  milder  symptoms 
(Holiest  Mir. 

Prognosis. — The  presence  of  an  echinococcus  cyst  may  be  of 
little  significance  if  it  be  taken  in  hand  early  and  properly  treated. 
The  fact  that  nearly  half  of  the  echinococcic  patients  die  within 


652 


PRINCIPLES   OF   SURGERY 


five  years  is  sufficient  comment  on  the  inadvisability  of  leaving 
them  untreated.  The  chance  of  spontaneous  cure  is  too  small  to 
be  relied  upon.  The  danger  of  spontaneous  or  traumatic  rupture 
is  always  present,  and  the  possibility  of  infection  remains  a  menace 
to  the  patient's  life.  Aspiration  across  a  serous  sac  for  diagnostic 
purposes  adds  to  the  unfavorableness  of  the  prognosis,  and  if 
done  the  needle  should  not  be  withdrawn  until  surgical  inter- 
vention has  been  done. 

Treatment. — The  ideal  treatment  is  to  remove  the  cyst  entirely 
from  the  fibrous  capsule  which  ensheaths  it,  having  the  utmost 


Fig.  221. — Trichina  spiralis.     (Microphotograph;  X  65.) 

care  not  to  permit  the  contents  to  escape  into  the  field  of  opera- 
tion. If  for  any  reason  removal  cannot  be  accomplished,  marsu- 
pialization  may  be  done  at  one  or  two  sittings,  and  the  cavity 
packed  and  caused  to  heal  from  the  bottom. 

Echinococcus  of  bone  may  require  simple  removal,  resection, 
or  amputation,  as  the  circumstances  determine. 

Cysticercus  Cellulosae. — This  form  of  cyst  is  of  compara- 
tively little  practical  concern  to  the  surgeon.  It  is  produced  by 
the  larval  form  of  the  Taenia  solium,  or  pig  tapeworm,  and  is  found 
much  more  frequently  in  the  flesh  of  hogs  than  elsewhere;  here  it 


CYSTS 


653 


constitutes  what  is  known  as  measley  meat,  the  individual  nodules 
being  spoken  of  as  "measles."  The  adult  worm  is  found  in  the 
alimentary  tract  of  man.  When  the  eggs  are  carried  into  the  human 
stomach  the  larval  form  appears  in  man,  being  found  in  the 
muscles,  subcutaneous  connective  tissue,  the  brain,  its  membranes 
and  ventricles,  hi  the  eye,  in  the  heart  muscle,  and  rarely  in  the 
liver  or  lungs.  They  appear  hi  great  numbers  and  widely  dis- 
tributed throughout  the  body.  The  eggs  are  taken  into  the  stom- 
ach from  without  or  are  brought  into  the  stomach  by  regurgita- 


V\li.  '2'1'1.  —  Trichina  spiralis.     Chronic  case.     Note  heavy  deposit  of  calcium 
salts  around  larva;.     (Microphotograph;  X  65.) 

tion  from  the  alimentary  tract  of  host"  of  T;rnia  solium,  and  follow 

then  the  .-anie  course  of  entrance  and  distribution  us  the  Taenia 
echinococcu-.  Thry  di-velop  int..  -mall  cysts  whose  sac  is  made 
of  new-formed  connective  tissue.  The  cyst"  vary  in  si/e  from  that 
of  a  pea  to  that  of  a  haxelnut,  and  may  live  in  great  numbers  in 
the  tissue  through  their  full  life  cycle,  from  three  to  twenty  years, 
without  producing  symptom-.  Naturally,  when  the  eye  or  the 
brain  is  atYected  special  >ymptom<  may  ari-e.  \\eakness  of  the 
muscles  appears  when  large  numl>er<  of  the  cyMs  develop. 

Treatment.— The  di-ra-«-   i-   self-limited   and   may   require  no 


654  PRINCIPLES   OF   SURGERY 

treatment.  If  inconvenience  is  produced  by  the  disease,  the  par- 
ticular nodules  causing  the  symptoms  are  to  be  removed  by 
excision. 

Dermoid  Cysts. — In  order  to  make  the  situation  clear,  it  is 
necessary  to  discuss  briefly  the  more  comprehensive  group  of  ab- 
normal growths  to  which  dermoids  belong,  namely,  teratomata. 
The  word  signifies  "monstrosity,"  but  its  application  pathologically 
is  much  more  comprehensive  than  the  limited  group  of  specimens 
which  originally  gave  origin  to  the  word.  A  teratoma  is  a  congeni- 
tal and  permanent  combination  of  a  greater  or  smaller  amount  of 


Fig.  223.— Teratoma  testis. 

tissues  or  organs  of  one  individual  with  another.  As  examples  may 
be  mentioned  the  cases  of  monochorial  or  dichorial  twins  and  those 
in  which  parts  of  one  individual  are  attached  to  another,  as  an 
extra  pair  of  legs  or  arms  or  an  extra  head.  These  represent 
monsters  pure  and  simple.  But  when  one  is  concealed  in  the  tis- 
sues of  another,  they  represent  the  group  with  which  we  are  espe- 
cially concerned  at  present. 

Origin. — It  is  impossible  to  discuss  hi  detail  the  numerous 
theories  that  have  been  offered  in  explanation  of  the  origin  of 
these  remarkable  growths.  Only  the  most  probable  explanation 
will  be  given.  There  is  no  doubt  that  teratomata  represent 


CYSTS  655 

the  growth  of  one  individual  more  or  less  complete  within  another 
which  serves  as  host.  The  source  of  this  growth  according  to  the 
most  plausible  theory  (Adami)  is  that  germinal  blastomeres,  which 
belong  to  the  group  of  cells  known  as  totipotent,  become  displaced 
and  ultimately  develop  into  a  teratoma.  These  cells  are  more 
abundant  in  the  testicle  and  ovary,  hence  the  great  frequency 
of  teratomata  in  these  organs,  but  they  may  be  remotely  dis- 
placed and  be  responsible  for  the  occasional  development  of  such 
Drouths  about  the  head.  These  totipotent  cells  are  the  ones  which 
transmit  the  capacity  to  reproduce  all  types  of  cells,  and  it  is 
consequently  from  them  that  the  ova  and  spermatozoa  are  formed. 


. 

I-'iu.  '_'•_' t.     Hank  of  hair  22  inches  long  removed  from  large  intra-abdominal 

•  I'Tinoid. 

These  latter,  however,  require  fertilization  to  assume  their  r61e 
of  reproduction,  so  that  the  blastomeres  which  form  embryomata 
mu.-t  l>e  more  elemental  than  these  specialized  forms,  for  the 
former  have  the  power  of  parthenogenetic  development. 

Structure. — The  simplest  form  of  dermoid  (skin-like)  cyst  is 
one  containing  a  ea>eou>  material  such  as  that  found  in  sebaceous 
eystfl  or  in  the  sequestration  cysts  which  are  often  classed  as  der- 
moids.  In  others  the  lining  of  the  sac  may  have  advanced  a  step 
further  in  its  resemblance  to  the  skin,  and  contain-  sweat-glands, 
sel.accoii<  glands,  and  hair-follicles  with  hairs  growing  from  them. 
In  yet  other  cases  additional  structures  appear,  as  mucous  mem- 
brane, connective  tissue,  hone,  teeth,  nails,  nerve  tissue,  and,  rarely, 


656  PRINCIPLES    OF   SURGERY 

other  structures.  The  hair  may  be  attached  or  lie  loose  in  the  cyst 
cavity;  it  may  be  abundant  or  scant.  Occasionally  there  are  shown 
in  the  cyst  evidences  of  an  attempt  to  develop  certain  more  com- 
plex structures,  such  as  mammary  glands. 

These  structures  are  either  solid  or  cystic.  In  the  former  case 
they  are  usually  small;  in  the  latter  they  may  attain  an  enormous 
size,  but  large  size  is  found  only  in  dermoids  of  the  ovary. 

Dermoid  cysts  grow  slowly,  and  are  to  be  recognized  by  their 
location,  their  slow  growth,  small  size  (except  ovarian  dermoids), 
and  their  signs  of  cystic  structure.  They  may  be  present  from 
birth,  but  frequently  begin  to  grow  only  at  or  soon  after  puberty. 
As  the  patient  grows  old  the  dermoid  may  shed  the  attached  hair, 
leaving  bald  spots.  The  hair  of  these  cysts  also  may  become  gray 
with  the  advent  of  old  age. 

Ovarian  dermoids  or  broad  ligament  dermoids  when  uncom- 
plicated produce  usually  moderately  large  cysts,  rarely  larger 
than  a  human  head.  The  very  large  cysts  are  usually  not  pure 
dermoids,  but  are  associated  with  a  cystadenoma.  Dermoids  of 
the  ovary  are  usually  unilateral  and  unilocular. 

Dermoid  cysts  of  the  ovary  are  especially  apt  to  become  in- 
flamed, rapidly  enlarge,  and  produce  extensive  adhesions. 

The  most  important  complications  of  dermoid  cysts  are  in- 
flammation and  the  development  of  cancer;  the  former  is  frequent, 
the  latter  rare. 

Dermoids  are  found  with  greatest  frequency  in  the  ovary,  the 
testicle,  the  sacrum  (inclusion  or  sequestration  cysts),  and  in  the 
face,  especially  at  the  outer  angle  of  the  orbit.  They  are  rarely 
found  in  the  thorax  or  upon  the  surface. 

Treatment  is  removal. 

Traumatic  Inclusion  Cysts. — Traumatic  inclusion  cysts  result 
from  the  implantation  of  portions  of  skin  into  the  subcutaneous 
tissues,  as,  for  instance,  when  a  blunt  nail  or  punch  is  driven  into 
a  part.  The  transplanted  skin  behaves  as  a  graft.  It  produces  its 
normal  secretion  and  gradually  assumes  a  rounded  form,  and 
finally,  by  proliferation  of  its  epithelium  and  the  formation  of  scar 
tissue,  forms  a  closed  sac.  The  contents  are  the  same  in  appear- 
ance as  in  sebaceous  cysts,  but  inclusion  cysts  may  contain  hairs. 
They  are  usually  found  on  the  hands. 

Treatment  is  excision. 


INDEX 


ABDOMINAL  viscera,  syphilis,  326 
Abscess,  145 

actinomycotic,  270 

acute,  pathology,  146 

alveolar,  147 

ainebic,  148 

atheromatous,  148 

Bezold's,  149 

Brodie's.  149 

canalicular,  149 

caseous,  149 

chronic,  149 

cold,  149,  279 
treatment,  307 

complications,  158 

congestive,  149 

constitutional,  149 

definition,  145 

diagnosis,  157 

drainage,  162 

dry.  149 

Dubois',  149 

edema,  156 

embolic,  149 

encysted,  150 

etiology,  145 

fecal,  150 

fluctuation,  155 

hepatic,  148 

Hilton's  treatment,  160 

i.-ehiorertal.  150 

lacunar,  150 

lumbar,   152 

marninal.   150 

mastoid,  150 

membrane,  200 

meta.-tatic,  150 

iniliarv,   150 

milk,   l.'.l 

mural,  1.11 

oea&fluent,  151 

Paget's,  153 

perforating,  151 

jMTincpliric.  151 

|>erinephritir,   1.11 
r,  152 


postpharytitfeal,  152 
progm>M~.  l.V.i 
peoas.  i.vj 
pyemic.  150 

42 


Abscess,  residual,  153 

retropharyngeal,  152 

secondary,  150 

sequels,  158 

shirt-stud,  153 

softening,  155 

stercoraceous,  150 

stercoral,  150 

stitch,  153 

stitch-hole,  153 

subdiaphragmatic,  153 

subphrenic,  153 

symptoms,  local,  154 

thecal,  154 

treatment,  159 
abortive,  159 
cleaning  cavity,  161 
drainage,  162 
operative,  159 

tropical,  148 

tuberculous,  279 
treatment,  307 

tympanitic,  154 

types,  147 

u  ri  i  KMI-.  154 
Absorption  of  pus,  143 

symptoms,  144 

Accidental  wounds,  sterilization,  64 
Accoucheur's  hand,  243 
Acephalocyst,  650 
Acia,  carbolic,  54 

gangrene  from,  193 
Acquired  immunity,  45 
Actinomycosis,  268 

diagnosis,  272 

etiology,  268 

of  alimentary  tract,  272 

of  jaws  and  mouth,  271 

of  lungs,  271 

of  skin,  271 

pathology,  269 

prognosis,  272 

symptoms,  270 

trcatmrnt,  273 
.VtinoMiycotir  abscess,  270 
Adami's  thi-ory  of  toxic  action,  38 
. Vli'iiofibroma  of  breast,  567 
Adenoma,  565 

of  alimentary  tract,  568 

of  intestine,  f>69 

of  kidneys,  568 

m 


658 


INDEX 


Adenoma  of  liver,  570 

of  mammary  gland,  567 

of  ovaries,  569 

of  salivary  glands,  568 

of  stomach,  568,  569 

of  thyroid  gland,  568 

of  uterus,  569 

pathologic  changes,  571 

prognosis,  571 

sites  of  formation,  567 

structure,  565 

symptoms,  570 

treatment,  571 

variations,  571 
Adenomatous  polyposis  of  intestine, 

569 

Adenomyoma,  496 
Adhesive  inflammation,  93 
Adrenalin  chlorid  in  hemorrhage,  347 
Aerobic  bacteria,  20 
Agglutinins,  36 
Ainhum,  195 
Air  emboli,  407 
Alcohol  as  antiseptic,  56 
Alexins,  36 

Alimentary  tract,  actinomycosis,  272 
adenoma,  568 
sarcoma,  521,  537 
Alopecia  in  syphilis,  315 
Alveolar  abscess,  147 
Amebic  abscess,  148 
Amputation  neuroma,  499 
Anaerobic  bacteria,  20 
Anel's  operation  for  aneurysm,  421 
Anemia,  hemolytic,  in  etiology  of  in- 
flammation, 97 

in  cancer,  607 
Anesthesia,  434,  437 

cause  of  death,  439 

choice,  438 

cocain,  434 

cold,  434 

danger  signals,  442 

death,  cause,  439 

emergencies,  441 

epidural,  437 

eucain,  434 

general,  437 

intraspinal,  436 

intravenous,  local,  436 

local,  434 

endermic  plan,  435 
intravenous,  436 

nausea  and  vomiting  after,  442 

novocain,  434 

physical  examination,  437 

preparation,  438 

relative  danger  of  anesthetics,  439 

sacral,  436 

surgical,  440 

vomiting  and  nausea  after,  442 
Aneurysm,  412 


Aneurysm,  Anel's  operation,  421 

Antyllus  operation,  420 

arterio venous,  414 
treatment,  423 

Brasdor's  operation,  420 

bruit,  417 

circumscribed,  414 

cirsoid,  413,  483 
treatment,  423 

classification,  412 

course,  418 

cylindric,  412 

diffuse,  414 

dissecting,  413 

etiology,  414 

false,  412 

Hunter's  operation,  421 

Lancereaux's  treatment,  419 

Matas'  operation,  421 

pathology,  415 

Philagrius'  operation,  420 

sacculated,  412 

symptoms,  416 

treatment,  419 

non-operative,  419 
operative,  420 

true,  412 

Tufnell's  treatment,  419 

types,  412 

Valsalva's  treatment,  419 

varicose,  414 

Wardrop's  operation,  421 
Aneurysmal  bruit,  417 

varix,  414 
Angioma,  483 

capillary,  483,  486 

cavernous,  483,  486 

classification,  483 

definition,  483 

diagnosis,  485 

etiology,  483 

pathologic  changes,  488 

plexiform,  483,  487 

prognosis,  488 

sites  of  formation,  485 

structure,  484 

treatment,  488 

variations,  488 
Angiosarcoma,  512,  517 
Anodynes,  local,  in  inflammation,  137 
Antagonistic  bacteria,  34 
Anthracemia,  260 
Anthrax,  257 

bacillus  of,  26 

complications,  260 

diagnosis,  260 

edema,  259 

erysipelas,  259 

etiology,  257 

external  type,  258 

general  infection,  259 

internal,  259 


INDEX 


669 


Anthrax,  pathology,  258 

prognosis,  260 

pulmonary,  260 

serum  treatment,  261 

treatment,  261 
Antisepsis,  47 
Antiseptic  agents,  47 
Antiseptics  in  scpticemia,  175 
Antitoxins,  37 

Antvllus'  operation  for  aneurysm,  420 
Anus,  fistula.  218 

.-inns,  hen'-.  220 

ulcer,  215 

treatment,  216 
Apparatus,  sterilization,  65 
Arborescent  lipoma,  478,  479 
•ivenous  aneurysm,  414 
treatment,  423 
Arthritis,  tuberculous,  292 
Ascites,  chylous,  428 
;s,  47 

chemic  method  of  producing,  51 

mechanical  method  of  producing,  47 

thermal  method  of  producing,  49 

'•  surgical  fever,  120 
Asphyxia,  local,  188 
Aspiration,  pus  on,  157 
Asthenic  inflammation,  93 
Atheroma,  633 
Atheromatous  abscess,  148 
Autogenous  vaccines,  43 


BACILLUS,  23,  25 

'•apsulatus,  26 

hospital  gangrene  due  to  infec- 
tion by,  191 
anthracis,  26,  257 

col.in,  •_'(', 
fusiformis,  27 
influcn/a-,  26 
mallei.  'Jti.  -JiVJ 
of  malignant  edema,  26 
of  tetanus,  25,  237 
1'feitTer's,  26 
pycicyaneus,  25 
pyogene>  fetiilus,  26 
tuberculosis,  25 
typho>u>.  •_'.") 

M.   17 

action  of  lymph-nodes  01 
aerobic.  20 
anaerobic.  '_'<) 

antagonistic,  34 

arrangement,  17 
atria  of  infection,  27 
Brownian  movement,  18 
carrier- 

characteri-ties.   17 
classification,  23 
color,  IN 
culture-medium,  20 


Bacteria,  distribution,  21 

elimination,  30 

epithelial  protection  against,  34 

essential  life  conditions,  20 

manner  of  producing  disease,  32 

mode  of  growth,  18 

moisture,  20 

motion,  18 

non-pathogenic,  23 

nourishment,  20 

pathogenic,  23 

point  of  entrance,  27 

protective  powers  of  body  against, 
34 

reproduction,  19 

saprogenic,  23 

saprophytic,  23 

shape,  17 

size,  17 

spores,  19 

staining,  19 

temperature,  20 
Bandage,   Esmarch's,   for  controlling 

hemorrhage,  342 

Beck's  bismuth  paste  in  sinus,  222,  223 
Bed-sore,  194 

treatment,  198 

Belladonna  in  inflammation,  137 
Benign  tumors,  444 
Bezold's  abscess,  149 
Bichlorid  of  mercury,  52 
Bier's  hyperemic  treatment  of  inflam- 
mation, 134-136 
Bilateral  sarcoma,  533 
Hil* --ducts,  cancer,  615 
Biniodid  of  mercury,  54 
Birth-murk.  4s:5.  4so 
Bismuth  paste,  Beck's,  in  sinus,  222, 

Black  tongue,  232 
Bladder,  cancer,  614 

preparation,  for  operation,  63 
Blast  omycosis,  334 

cutaneous,  334 

definition,  334 

diagnosis,  33 n 

etiology,  334 

pathology,  334 

prognosis,  335 

systemic,  335 

treatment,  336 

Bla.-tomycotir  dermatitis,  334 
Bleb-  in'fractur*',  388 
Blindness  after  erysipelas,  2:t3 
Blocking,  nerve-,  435 
Blood,  exudation,  in  inflammation,  103 

quality,    deficiency,    in    etiology   of 
inflammation,  96 

quantity,  deficiency,  in  etiology  of 
inflammation,  97 

spread  of  inflammation  by,  106 

transfixion,  in  >epticemia,  175 


660 


INDEX 


Blood-cells,  oscillation,  102 
Blood-count  in  septicemia,  171 
Blood-letting,  local,  in  inflammation, 

129 

Blood-pressure  in  septicemia,  172 
Blood-vessels,  dilatation,  101 

grafting,  90 
Blue  pus,  141 

Blunk's  shearing  hemostat,  344 
Boil,  145 

Boiling  water,  sterilization  by,  50 
Bone  cysts,  645 

healing,  77 

hemorrhage  from,  control,  347 

hypertrophy,  syphilitic,  321 

myelogenous  sarcoma,  519,  543 

periosteal  sarcoma,  519 

sarcoma,  518,  540 

syphilis,  320 
hereditary,  322 

transplantation,  88 

tuberculosis,  288 

treatment,  304,  305 
Bone-felon,  146 
Bone-grafting,  88 
Bordet's  law,  36 
Bottom,  weavers',  640 
Boyer's  cyst,  640 
Brain,  sarcoma,  520,  545 

syphilis,  330 
Branchial  cysts,  641 
Branchiogenic  chondroma,  455 
Brasdor's  operation  for  aneurysm,  420 
Breast,  adenoma,  567 

cancer,  608 

Halsted's  sign,  609 

cysts,  637 

Brodie's  abscess,  149 
Brownian  movement  of  bacteria,  18 
Bruit,  aneurysmal,  417 
Brush  wounds,  357 
Buds,  capillary,  68 
Burns,  371 

degrees,  371 

electric,  treatment,  377 

etiology,  371 

of  first  degree,  371 
treatment,  376 

of  fourth  degree,  374 

of  second  degree,  371 
treatment,  376 

of  third  degree,  372 
treatment,  376 

pathology,  374 

prognosis,  375 

radium,  treatment,  377 

symptoms,  constitutional,  374 

treatment,  375 

x-ray,  treatment,  377 
Bursa,  syphilis,  325 
Bursitis,  gummatous,  325 

syphilitic,  325 


CACHEXIA  in  cancer,  607 

in  sarcoma,  533 

in  tumors,  449 
Callous  ulcer,  204 
Callus,  78 

luxurians,  459 

provisional,  78 
Calor,  110 

Canah'cular  abscess,  149 
Cancellated  osteoma,  459 
Cancer,  572 

age  occurring,  599 

anemia,  607 

aquaticus,  92 

cachexia,  607 

cells,  582,  583 

classification,  572 

colloid,  572,  587 

consistence,  599,  601 

cutaneous  reaction,  608 

cylinder-cell,  572 

definition,  572 

degeneration,  605 

diagnosis,  593,  596 

en  cuirasse,  610 

encapsulation  in,  600 

etiology,  573 

fever,  607 

fulguration,  628 

gastric,  612 

glandular,  572 

growth,  589 
rate,  597 

hemorrhage,  605,  606 

implantation,  604 

infection,  606 

inoperable,  treatment,  629 

insane  cells,  577 

juice,  580 

lymphatic  involvement,  601 

metastasis,  590,  602 

mucous,  587 

multiple  primary  growths,  608 

of  bile-ducts,  615 

of  bladder,  614 

of  breast,  608 

Halsted's  sign,  609 

of  gall-bladder,  615 

of  intestines,  616 

of  liver,  614 

of  stomach,  612 

of  uterus,  610 

operative  treatment,  624 

pain  in,  600 

period,  599 

perles,  585 

prognosis,  619 

Ribbert's  classification,  572 
views  of  origin,  573 

scirrhous,  587,  610 

shape,  601 

sites  of  formation,  592 


INDEX 


661 


Cancer,  skin  reaction,  608 

squamous-celled,  572 

structure,  577 

surface  appearance,  598 

treatment,  623 
operative,  624 

ul<  eration,  605 

variations,  618 

x-rays,  627 
Cancrum  oris,  92 

treatment,  197 
Capillary  ungioma,  483,  486 

buds,  68 

loops,  t>S 
Carbolic  acid,  54 

gangrene,  193 
Carlmnele,  146 

treatment,  164 

Carcinoma,  572.     See  also  Cancer. 
Carcinomatosis,  general,  604 
Caries,  gummatous,  321 

of  scapula,  289 

of  spinal  column,  tubercular,  289 

sicca,  289,  295 

syphilitic,  321 
Carriers'  bacteria,  22 

typhoid,  22 

Cartilage,  tuberculosis,  288,  291 
Ca>e<>u-  abaoeflB,  I41.' 

tiiberrulous  osteomyelitis,  289 
Catarrhal  inflammation,  93 
Cautery,  49 

in  hemorrhage,  346 
Cavernous  aniiioma,  483,  486 

lympliaimioma,  490 

Cell  rarta,  I.YJ 

Cells,   caiu-er.   W2,  583 

connective-tissue,  69 

insane.    J.'il.  ~t~7 

totipotent,  655 
( 'eini-nioriia,  644 
Ceplialeinatoina,  M't 
Cerebrospinal  meningitis,  tetanus  and, 

different  iat  ion,  244 
Cerulean  pus,  141 
Chala/ion.  i',:;7 
Chancre.  :;]  1 

Charnon.  -j.'iT.     See  also  Anthrax. 
Chi-li.i.l.   17:; 

Cliemie  proli-elive  JM)\vers,  'M 

rili/ation,  .".1 
Chemotaxi-.  :;.", 

negative.  : 

positive, 

ChilMain-.  :;7s 

treatment.  :{sl 
Chill  in  inflammation.  120 
Cliloronia,  .">.">S 
Cholesteatoma,  M2 
Chondroma.    I 

branchiogcnic.    J.'i.'i 

classification,  453 


Chondroma,  definition,  453 

diagnosis,  455 

etiology,  454 

fractune,  454 

pathologic  changes,  457 

prognosis,  457 

sites  of  formation,  455 

structure,  454 

treatment,  458 

variations,  457 
Chondrosarcoma,  502,  512,  540 

diagnosis.  534 
Chorion  epithelioma,  616 
Chvostek's  sign  in  tetany,  243 
Chyle  cysts,  637 

mesenteric,  638 
Chylothorax,  428 
Chylous  ascites,  428 
Cicatrization  in  healing,  70 
Circumscribed  aneurysm,  414 
Cirrhosis,  syphilitic,  327 
Cirsoid  aneurysm,  413,  483 

treatment,  423 
Cloacae,  291 
Cocain  anesthesia,  434 

in  inflammation,  137 
Coccus,  23 
Cohnheim's  theory  of  origin  of  tumors, 

451 

Cold  abscess,  149,  279 
treatment,  307 

as  anesthetic,  434 

finger,  188 

in  treatment  of  inflammation,  130 

low  degree,  effects,  378 
Coley's  fluid  in  sarcoma,  34,  236,  557 
Collapse,  349.     See  also  Shock. 
Colloid  cancer,  572,  587 
Colon  bacillus,  26 

sigmoid,  ulcer,  215 
treatment,  217 

Compression  in  inflammation,  129 
Concealed  hemorrhage,  340 
Condyloma,  pointed,  562 

treatment,  563 
Con^i-nital  cystic  hygrpma,  638 

kidney,  lifj 
Congested  nicer,  207 
( '"UL'estion,  102 

(  'onue.stive   ali.-c.  — .    1  1'.' 
Connective  ti— ne,  sarcoma,  517 
Connect i\e-ti-Mir  ci  Us,  69 

tumors,  452 

Constitutional  abscess,  149 
Contused  wound-.  :\:*\ 
Cornu  cutaneiim,  563 
Corpora  lutea,  cyst8;  640 
Counterirritation  iti  inflammation,  132 
( 'ourvoisier's  law.  til.'. 
C'reolin.   ~>~> 

Crepitus  in  fracture,  385 
'  "" 


662 


INDEX 


Crile's  pneumatic  suit  in  shock,  354 
Crossed  emboli,  405 
Croupous  inflammation,  94 
Cutaneous  blastomycosis,  334 
horns,  563 

reaction  in  cancer,  608 
Cylinder-cell  cancer,  572 
Cylindric  aneurysm,  412 
Cylindroma,  572 
Cystadenoma,  646 
Cystic  gall-bladder,  636 
hygroma,  491 

congenital,  638 
kidney,  congenital,  642 
tumors,  645 

treatment,  647 
Cysticercus  cellulosae,  648,  652 

treatment,  653 
Cysts,  631 
Boyer's,  640 
branchial,  641 
characteristics,  631 
chyle,  637 

mesenteric,  638 
classification,  632 
complications,  632 
contents,  631 
definition,  631 
dentigerous,  643 

treatment,  644 
dermoid,  654 

origin,  654 

structure,  655 

treatment,  656 
duct,  635 
echinococcus,  649 

diagnosis,  651 

prognosis,  651 

treatment,  652 
embryonal,  640 
extravasation,  640 
exudation,  639 
hemorrhagic,  644 

treatment,  645 
hydatid,  649 
inclusion,  traumatic,  656 
lymphatic,  637 
mucous,  635 
nabothian,  635 
necrotic,  647 
of  bone,  645 
of  breast,  637 
of  corpora  lutea,  640 
of  Graafian  follicles,  640 
of  new  formation,  644 
of  pancreas,  637 
of  parotid  gland,  635 
of  Stenson's  duct,  635 
of  submaxillary  gland,  635 
of  urachus,  641 
of  vulvovaginal  glands,  637 
of  Wolffian  body,  641 


Cysts,  parasitic,  648 
retention,  633 
sebaceous,  633 

treatment,  635 
sequestration,  641 
structure,  631 
thyroglossal,  641 
traumatic  inclusion,  656 
vitello-intestinal,  642 

DACTYLITIS,  syphilitic,  322 
Debris  of  pus,  141 
Decubitus,  194 

treatment,  198 
Deformity  in  fracture,  387 
Degeneration  of  cancer  tissue,  605 

of  tumors,  450 
de  Keating-Hart  fulguration  in  cancer, 

628 
Delayed  union  in  fracture,  391 

treatment,  392 

Delitescence  in  inflammation,  107 
Dentigerous  cysts,  643 

treatment,  644 

Dermatitis,  blastomycotic,  334 
Dermoid  cysts,  654 
origin,  654 
structure,  655 
treatment,  656 
Desmoid,  465 
Diabetic  gangrene,  187 

ulcer  of  leg,  201 

Diapedesis  in  inflammation,  103 
Diffuse  inflammation,  93 
Dilatation  of  blood-vessels,  101 
Diphtheric  inflammation,  94 
Diplococci,  23 

Discoloration  in  inflammation,  111 
Dislocations,  394 

bilateral,  394 

classification,  394 

complete,  394 

complicated,  394 

diagnosis,  394 

etiology,  394 

partial,  394 

prognosis,  396 

recurrent,  394 

simple,  394 

treatment,  396 

unilateral,  394 

Displacement,   spontaneous,    in   frac- 
ture, 386 

Dissecting  aneurysm,  413 
Dolor,  110 

Drainage  in  abscess,  162 
Drainage-tubes,  163 
Dressings  and  fabrics,  sterilization,  65 

in  Reverdin's  method  of  skin-graft- 
ing, 83,  84 

in  Thiersch's  method  of  skin-graft- 
ing, 86 


INDEX 


Drugs,  hygroscopic,  in  inflammation, 

134 
Dry  abscess,  149 

gangrene,  181 

inflammation,  95 

sterilization,  49 
DuboLs'  abscess,  149 
Duct  cysts,  635 
Dumb  rabies,  252 
Duodenal  ulcer,  212,  214 
treatment,  214 


EATING  ulcer,  211 
Ecchondroma  ossificans,  453 

simplex,  453 

Ecchymosis  in  fractures,  388 

Echinococcus  cysts,  649 

diagnosis,  651 

prognosis,  651 

treatment,  652 

hydatidosus,  649 
Edema,  anthrax,  259 

in  abscess,  156 

lymph-,  428 
treatment,  429 

malignant,  bacillus  of,  26 
Klirlii-ITs  side-chain  theory,  37 
Elbow,  miners',  640 
Klectric  burns,  treatment,  377 
Elephantiasis,  430 

after  erysipelas,  233 

arabum,  430 

complications,  433 

definition,  430 


etiology,  430 
filariosa,  430 
lia-mangiomatosa,  488 
nervorum,  472 
neuromatosa,  430 
nostras,  430 

of  nose,    }:« 

pathology.  -t:;o 
phlebectatica,  430 

progi 

treatment,  433 
Klevated  ulcer,  211 
Klevation  in  inflammation,  128 
Kmbolic  abscess,  149 
Embolism,  403 
ive,  403 

air,  407 

bland,  403 

crossed,  405 

favorite  -ites  of  lodgment,  408 

j)arado\ic.    lti."> 

pathologic  consequences,  404 

(xiints  of  lodirment,  405 

prognosis.   ID1.  i 

source-,    to:; 

symptoms,  406 


Embolism,  treatment,  410 
Embolus,  403.     See  also  Embolism. 
Embryonal  cysts,  640 
Embryonic  tissue,  68 
Emphysema,  gangrenous,  186 
Kmprosthotonos,  241 
Encapsulation  in  cancer,  600 

of  sarcoma,  529 

of  tumor,  445 
Enchondroma,  453 
Encysted  abscess,  150 
Endo-aneurysmorrhaphy,  421 
Endocarditis  in  erysipelas,  232 
Endothelioma,  502,  558 
Enlargement,  sudden,  in  sarcoma,  532 
Epiblastic  tumors,  452 

benign,  561 

Epidemic  erysipelas,  232 
Epidermization  in  healing,  70 
Epidural  anesthesia,  437 
Epiphyseal  separation,  384 
Epiphysitis,  tubercular,  292 
Epithelial  protection  against  bacteria, 

34 
Epithelioma,  572 

choriont  616 

diagnosis,  593 

ulcerative,  211 
Epulis,  475,  541 

Equinia,  262.     See  also  Glanders. 
Era's  sign  in  tetany,  243 
Erethistic  ulcer,  207 
Ergot  gangrene,  189 
Eruption  of  syphilis,  312 
Erysipelas,  226 

anthrax,  259 

complications,  232 

curative  action,  236 

diagnosis,  233 

epidemic,  232 

erythematosum,  229 

etiology,  226 

facial,  230 

fulminating,  229 

gangrenous,  229 

habitual,  2:50 

idiopathic,  326 

metastatic,  229 

neonatorum,  231 

of  face,  230 

of  head,  230 

of  newborn,  231 

pathologic  changes,  227 

phlegtnotiosum,  229 

prognosis,  233 

pustulosum,  229 

recurrent 

sequels,  'j:w 

serum  treatment,  '2'M 

symptoms.  -J-J7,  228 

t realm, •nt,  234 

types,  229 


664 


INDEX 


Erysipelas  vesiculosum,  229 
wandering,  229 

Erysipelatis  ambulans,  229 
migrans,  229 

Esmarch's  elastic  bandage  for  control- 
ling hemorrhage,  342 

Esophagus,  sarcoma,  521 

Ether  as  antiseptic,  56 

Eucain  anesthesia,  434 

Extravasation  cysts,  640 

Exuberant  ulcer,  203 

Exudation  cysts,  639 

of  blood  in  inflammation,  103 


FACIAL  erysipelas,  230 

tetanus,  242 

Facies  in  inflammation,  121 
False  aneurysm,  412 

neuroma,  499 
Farcy,  262 

chronic,  264 

diagnosis,  265 

prognosis,  266 

symptoms,  263 

treatment,  266 
Fascia,  sarcoma,  517 

tuberculosis,  296 
Fecal  abscess,  150 
Felon,  146 

treatment,  164 
Fetid  pus,  140 
Fever  in  cancer,  607 

in  inflammation,  119 

in  sarcoma,  533 

in  syphilis,  314 

postoperative,  120 

syndrome,  120 
Fibrinous  inflammation,  93 
Fibro-adenoma  of  breast,  567 
Fibroblasts,  68 

source,  68 

Fibroids,  465.     See  also  Fibroma. 
Fibrolipoma,  481 
Fibroma,  465 

cavernosum,  468 

classification,  465 

definition,  465 

diagnosis,  467 

durum,  465 

forms,  470 

lymphangiectaticum,  468 

molle,  472 

molluscum,  465,  472 

pathologic  changes,  468 

prognosis,  470 

sites  of  formation,  466 

structure,  466 

telangiectaticum,  468 

treatment,  470 

variations,  467 
Fibromyoma,  467 


Fibroplastic  inflammation,  93 
Fibrosarcoma,  516 

diagnosis,  534 
Fibrous  orchitis,  329 
Filaria  sanguinis  hominis,  430 
Fissure  in  ano,  207 

of  lip,  207 
Fissures,  384 
Fistula,  218 

diagnosis,  220 

etiology,  218 

in  ano,  218 

pathology,  220 

treatment,  222,  224 
Fluctuation  of  abscess,  155 
Fractional  sterilization,  51 
Fracture,  382 

blebs,  388 

chondroma,  454 

comminuted,  383 

complicated,  383 

compound,  383 

counterextension,  388 

crepitus,  385 

deformity,  387 

delayed  union,  391 
treatment,  392 

denticulated,  384 

depressed,  384 

double,  383 

ecchymosis,  388 

etiology,  382 

extension,  388 

false  union,  389 

green-stick,  384 

healing,  77 

immobilization,  389 

impacted,  384 

incomplete,  384 

Lane's  method  of  treatment,  392 

longitudinal,  384 

manipulation,  389 

multiple,  383 

oblique,  384 

osteoma,  459 

pain,  387 

preternatural  mobility,  386 

pseudarthrosis,  391 

reduction,  388 

serrated,  384 

simple,  383 

single,  383 

skiagraphy,  387 

spiral,  384 

spontaneous  displacement,  386 

symptoms,  385 

transverse,  384 

treatment,  388 
open  method,  392 

types,  383 

unilateral,  384 

union,  77 


INDEX 


(105 


Fracture,  union,  delayed,  391 

treatment,  392 
false,  391 
vicious.  391 

unnatural  mobility,  386 

ununited,  391 
treatment,  392 

vicious  union,  391 
Free/ing. 

F remit  us  in  inflammation,  117 
Frost-bite,  378 

first  degree,  378 

fourth  degree,  379 

pathology,  378 

prognosis.  3M) 
ad  degree,  379 

symptoms,  379 

third  degree,  379 

treatment.  :>M) 
.Fulguratipn  in  cancer,  628 
Fulminating  erysipelas,  229 

gangrene,  186 

inflammation,  92 
Functio  ISES&,  110 
Function,  impaired,  in  inflammation, 

115 

Fungous  ulcer,  203 
Fungus,  ray-.  268 

sarcomatoaes,  523 
Furuncle,  145 

GALACTOCELE,  637 
Gall-bladder,  cancer,  615 

-•ic,  636 
Gangrene,  179 
carbolic  acid,  193 
diabetic,  187 
<lry,  181 
due  to  infection  by  Bacillus  aerog- 

ones  capsulatus,  191 
ergot,  189 
etiology,  179 
fmidroyante,   186 
fulminating,    l^i 
gummatous,  321 
hospital.   ivi 

diphtheric  type,  190 

pulpy  type,  190 

ulcerative  type,  190 
in  inflammation,  108 
line  of  demarcation,  184 
microliic.   1st! 
moi.-t,  1M 
pain,  183 
Raynaud's,  188 
senile,  184 

spreading  traumatic,  186 
symmetric,   188 
symptoms,  gem-ral,   lst 
syphilitic.  :;_'! 
treatment,  195 
Gangrenous  emphysema,  186 


Gangrenous  erysipelas,  229 

inflammation,  94 
Gastric  cancer,  612 

ulcer,  212 
acute,  214 
chronic,  212 

complications  and  sequels,  214 
treatment,  214 
General  carcinomatosis,  604 
Germs,  17.     See  also  Bacteria. 
Giant-celled  sarcoma,  502 
Gibson's  chart  in  inflammation,  122 
Glanders,  262 

chronic,  265 

diagnosis,  265 

etiology,  262 

pathology,  262 

prognosis,  266 

symptoms,  262,  264 

treatment,  266 
Glandular  cancer,  572 

skin-cancer,  572 
Glioma,  500 

diagnosis,  500 

durum,  500 

hard,  500 

molle.  500 

prognosis,  501 

sites  of  formation,  500 

soft,  500 

structure,  500 

treatment,  501 
Gliosarconra.  retinal,  501 
Graafian  follicles,  cysts,  640 
Grafting,  bone-,  88 

of  blood-vessels,  90 

of  kidneys,  90 

of  mucous  membrane,  90 

of  muscles,  90 

of  nerves,  90 

of  tendons,  90 

skin-,  79.     See  also  Skin-grafting. 
Granulating  ulcer,  203 
Granulation  tissue,  68 
Green  pus.  141 
Green-stick  fracture,  384 
Grossich's  method  of  sterilization  of 

operative  field,  56,  57,  62 
Gum-boil,  147 

( iumnia.  317 

diagnosis,  318 

gross  appearance,  317 

of  liver,  328 

of  muscles,  326 
Ciummatous  bursitis,  325 

carie>.  321 

myo.-itis.  :{4_'o 

necrosis,  321 

orchitis,  329 
Gunshot  wounds,  357 
infection,  iit'.l 
treatment,  368 


666 


INDEX 


HABITUAL  erysipelas,  230 

Halsted's  sign  in  cancer  of  breast,  609 

Hand,  obstetric,  243 

Hands,  sterilization,  58 

Hard  glioma,  500 

warts,  561 

Harrington's  solution,  53 
Head,  erysipelas,  230 

tetanus,  242 
Healing,  66 

by  first  intention,  67 

by  second  intention,  71 

appearance  of  wound,  73 

by  third  intention,  74 

cicatrization,  70 

epidermization,  70 

of  bone,  77 

of  fracture,  77 

of  muscle,  77 

of  nerves,  75 

of  soft  structures,  66 

of  tendon,  77 

ulcer,  203 

under  scab,  74 
Healthy  inflammation,  95 

ulcer,  203 
Heat  in  inflammation,  130 

in  treatment  of  inflammation,  130 

sterilization  by,  49 
Heliotherapy  in  tuberculosis,  304 
Hemangio-endothelioma,  558 
Hemangioma,  483.    See  also  Angioma. 
Hemolysins,  33 

Hemolytic  anemia  in  etiology  of  in- 
flammation, 97 
Hemophilia,  348 
Hemorrhage,  340 

active,  control,  343 

adrenalin  chlorid  in,  347 

cautery  in,  346 

concealed,  340 

control,  342 

of  active  bleeding,  343 
permanent,  343 

drugs  in,  347 

Esmarch's  elastic  bandage  for  con- 
trolling, 342 

from  bone,  control,  347 

in  cancer,  605,  606 

in  tumors,  449 

ligation  in,  344 

Momberg's  method  of  controlling, 
343 

packing  in,  346 

permanent  control,  343 

pressure  in,  343,  344 

secondary,  348 

symptoms,  341 

torsion  in,  345 
Hemorrhagic  cysts,  644 
treatment,  645 

inflammation,  95 


Hemorrhoids,  thrombotic,  399 
Hen's  anus  sinus,  220 
Hepatic  abscess,  148 
Hereditary  syphilis,  316 

of  bone,  322 

Heterogenous  vaccines,  43 
Heterologous  tumors,  452 
Hilton's  law,  117 

method  of  treating  abscess,  160 
Homologous  tumors,  452 
Horns,  cutaneous,  563 
Hospital  gangrene,  189 
diphtheric  type,  190 
pulpy  type,  190 
ulcerative  type,  190 
Hot-air  sterilization,  51 
Housemaids'  knee,  640 
Hunter's  operation  for  aneurysm,  421 
Hydatid  cysts,  649 

mole,  malignant,  617 
Hydrocele,  639 

of  cord,  641 
Hydrogen  peroxid,  58 
Hydronephrosis,  636 
Hydrophobia,  249 

destruction  of  virus,  250 

diagnosis,  254 

dumb,  252 

etiology,  249 

in  dog,  251 
symptoms,  251 

Negri  bodies,  251 

paralytic  stage,  254 

Pasteur  treatment,  256 

pathology,  250 

premonitory  stage,  253 

prognosis,  255 

stage  of  excitement,  253 

stages,  252 

tetanus  and,  differentiation,  244 

treatment,  255 
Hygroma,  congenital  cystic,  638 

cystic,  491 

cysticum  colli  congenitum,  491 
Hygroscopic   drugs  in  inflammation, 

134 

Hyperemia,  101 

Hyperemic  treatment,   Bier's,   in  in- 
flammation, 134-136 
Hypernephroma,  546 
Hypertrophic  ulcer,  203 
Hypertrophy,  bone,  syphilitic,  321 
Hypoblastic  tumors,  452 

benign,  561 

Hypostatic  inflammation,  92 
Hysteria,  tetanus  and,  differentiation, 

243 

ICHOROUS  pus,  140 
Idiopathic  erysipelas,  226 
multiple     pigmented     sarcoma     of 
skin,  517 


INDEX 


667 


Idiopathic  tetanus,  241 
Immobility  of  sarcoma,  529 
Immobilization  in  fracture,  389 
Immunity.  44 

acquired,  45 

natural,  45 

racial,  45 

Implantation  cancer,  604 
Incited  wounds,  355 
Inci.-ion  in  inflammation,  130 
Inclu.-ion  cysts,  traumatic,  656 
Index,  opsonic,  41 
Indolent   ulcer,  204 
Infection  in  cancer,  606 

mixed,  33 

significance,  30 
Infective  inflammation,  92 
Infiltration  of  sarcoma,  529 

of  tumors,  445 
Inflammation,  91 

acute,  92 

adhesive,  93 

anodynes,  local,  137 

asthenic,  93 

belladonna  in,  137 

Bier's  hyperemic   treatment,    134- 
196 

blood-letting,  local,  129 

catarrbal,  93 

chill  in,  120 

chronic,  92 

cocain  in,  137 

cold  in  treatment,  130 

compression  in,  129 

counterirritation  in,  132 

croupous,  94 

definition,  91 

delitescence,    107 

destruction  of  tissue,  104 

ili.-mno-i-.  123 

diap<-deM~  in,  103 

diffuse,  '.»:; 

diminished  radiation  in,  111 

diphtheric,  94 

disrolorat  imi  in,  111 

dry,  '.»:, 

elevation  in,  128 

etioli.ny,  95 

deficiency  in  quality  of  blood  or 

ti.-.-ueSj  97 

in  (plant ity  of  blood,  96 
i'hiK.  99 

predisposing,  96 

•••nt.   100 
exudation,  103 
facies  in.   1'Jl 
fever  in,  119 
fibrinoplastic,  93 
fibrinou- 
fremitus  in,   I  17 
fulminating,  92 
gangrenou 


Inflammation,  Gibson's  chart,  122 
healthy,  95 
heat  in.  110,  130 
hemorrhage,  95 
hygroscopic  drugs  in,  134 
hypostatic,  92 
impaired  function  in,  115 
incision  in,  130 
increase  of  elimination,  137 

of  general  resistance,  138 

of  specific  resistance,  J38 
infective,  92 
interstitial,  93 
latent,  95 
leeches  in,  130 
leukocytosis,  121 
magnesium  sulphate  in,  137 
massage  in,  133 
moist,  95 

muscular  rigidity  in,  117 
neuropathic,  92 
new  tissue  formation  in,  109 
of  non-muscular  tissue,  104 
operative  treatment,  139 
opium  in,  137 
pain  in,  111-115 
parenchymatous,  93 
phenomena,  101 
plastic,  93 
position  in,  128 
pressure  in,  129 
prognosis,  124 
proliferative,  95 
pulse  in,  120 
puncture  in,  130 
purulent,  94 
redness  in,  111 
regeneration,  104 
removal  of  cause,  125 
resolution  in,  107 
rest  in,  126 
rhexis  in,  103 
scarification  in,  130 
serous,  93 
sinus,  109 

general  or  constitutional,  118 

local,  110 
soreness  in,  114 
spread,  105 

by  blood,  105 

by  continuity,  105 

by  continuity.  105 

by  lymphatics,  106 
sthenic,  93 
subacute,  93 
suppurative,  94,  107 
swelling  in,  116 
sympathetic,  «rj 
symptoms,  109 

general  or  constitutional,  118 

local,    HO 

tenderness  in,  114 


668 


INDEX 


Inflammation,  terminations,  106 

traumatic,  92 

treatment,  125 
constitutional,  137 
general,  137 
local,  125 
operative,  139 

unhealthy,  95 
Influenza,  bacillus  of,  26 
Inoperable  cancer,  treatment,  629 
Insane  cells,  451,  577 
Instruments,  sterilization,  64 
Interstitial  inflammation,  93 
Intestinal  mycosis,  260 
Intestine,  adenoma,  569 

adenomatous  polyposis,  569 

cancer,  616 

sarcoma,  521,  539 
Intoxication,    septic,    165.     See    also 

Sapremia. 

Intracystic  papilloma,  564 
Intraspinal  analgesia,  436 
Intravenous  local  anesthesia,  436 
Involucrum,  291 
lodin,  56 

Irritable  ulcer,  207 
Ischiorectal  abscess,  150 
Ivory  osteoma,  459 


JAW,  actinomycosis,  271 

lumpy-,  269 
Joints,  syphilis,  324 
tuberculosis,  292 
symptoms,  295 
treatment,  305,  306 


KELOID,  473 

treatment,  475 
Kidneys,  adenoma,  568 

congenital  cystic,  642 

sarcoma,  545 

transplantation,  90 

tuberculosis,  296 
symptoms,  297 
treatment,  304 
Knee,  housemaids',  640 
Krause's  method  of  skin-grafting,  87 


LACERATED  wounds,  357 

Lacunar  abscess,  150 

Lancereaux's  treatment  of  aneurysm, 
419 

Lane's  method  of  treatment  of  frac- 
tures, 392 

Larynx,  tuberculosis,  treatment,  308 

Latent  inflammation,  95 

Laudable  pus,  140 

Law,  Bordet's,  36 
Courvoisier's,  615 


Law,  Hilton's,  117 

of  Metschnikpff,  35 

of  Wyssokowickz,  34 
Leeches  in  inflammation,  130 
Leg,  milk-,  399 

Leiomyoma,  494.     See  also  Myoma. 
Leukocidin,  24 
Leukocytes,  migration,  102 
Leukpcytpsis  in  inflammation,  121 
Ligation  in  hemorrhage,  344 
Line  of  demarcation  in  gangrene,  184 
Lip,  fissure,  207 
Lipoma,  478 

arborescens,  478,  479 

classification,  478 

definition,  478 

diagnosis,  481 

diffuse,  478 

etiology,  479 

myxomatodes,  462 

myxomatous,  482 

pathologic  changes,  482 

prognosis,  482 

sites  of  formation,  479 

structure,  479 

telangiectaticum,  482 

treatment,  482 

variations,  481 
Lipomyxoma,  462 
Liquor  puris,  141 
Liver,  adenoma,  570 

cancer,  614 

gumma,  328 

sarcoma,  521,  547 

syphilis,  327 

Lockjaw,  237.     See  also  Tetanus. 
Loops,  capillary,  68 
Lumbar  abscess,  152 
Lumiere  and  Becue's  method  of  stain- 
ing sporotrichum,  338 
Lumpy- jaw,  269 
Lungs,  actinomycosis,  271 

sarcoma,  549 

Luxation,  394.      See  also  Dislocation. 
Lymphadenitis  in  erysipelas,  233 

scrofulous,  281 
Lymphangiectases,  428 

treatment,  429 

Lymphangio-endothelioma,  558 
Lymphangioma,  490 

cavernous,  490 

classification,  490 

cysticum,  491 

diagnosis,  492 

etiology,  491 

pathologic  changes,  493 

prognosis,  493 

simple,  490 

sites  of  formation,  492 

structure,  491 

treatment,  493 

variations,  493 


INDEX 


IKK) 


Lymphangitis  in  erysipelas,  233 

syphilitic,  319 
Lymphatic  cysts,  637 
Lymphatics,  spread  of  inflammation 

by,  106 
Lymph-edema,  428 

treatment,  429 
Lymphendothelioma,  517 
Lymph-nodes,  action,  on  bacteria,  35 

enlargement,  in  syphilis,  314 
in  tumors,  446 

involvement,  in  cancer,  601 

sarcoma,  519 

syphilis,  319 

tubercular,  280 
diagnosis,  283 
subsequent  course,  282 
treatment,  305 
Lymphosarcoma,  504,  511,  520 

diagnosis,  535 

Lymph- vessels,  syphilis,  319 
Lysol,  55 
Lyssa,  249.     See  also  Hydrophobia. 


MACROCHEILIA,  492 

Macroglossia,  492 

Magnesium  sulphate  in  inflammation, 

137 
Malignant  chprion  epithelioma,  616 

edema,  bacillus  of,  26 

hydatid  mole,  617 

pOBfcule,  257.     See  also  Anthrax. 

tumors,  444 

Mall.  -u>.  262.     See  also  Glanders. 
Malum  perfonins  pedis,  208 
Mammary  gland,  adenoma,  567 

' 


I,  637 

Marginal  alxcoss,  150 
Marjoliii'-  ulcer,  211 
Massage  in  inflammation,  133 
Mastoid  abscess,  150 
Matas'  operation  for  aneurysm,  421 
M.  .i-le>,  (>48,  653 
Mechanical  sterilization,  47 
Meilullary  osteoma,  459 
Melanoeareinoma,   ">11 
Mel.-uiotir  sarcoma,  ."ill 
Meiiinges,  -arcoma,   ~>\~t 
Meningitis,  cerehrospinal,  tetanus  and, 
(liffereiitiation,  244 

in  ery-ipela.-.  . 
Mercury.  luchlorid,  52 

liinio'li'i.  54 

in  syphilis  :;::_' 
Meseiiteric  chyle  cysts,  638 
Mi-olila.-t  ic  tumor-,    l.VJ 
Mesotheliomu, 

Met;i-t:i-es   ill   cancer,  590,  602 

in  sarcoma,  .'»:51 
in  tumor-.   I  17 


Metastatic  abscess,  150 
erysipelas,  229 

Metschnikoff,  law  of,  35 

Microbes,  17.     See  also  Bacteria. 

Microbic  gangrene,  186 

Micro-organisms,   17.    See  also  Bac- 
teria. 

Miliary  abscess,  150 

Milk  abscess,  151 

Milk-leg,  399 

Miners'  elbow,  640 

Mixed  infection,  33 
tumors,  452 

Mixed-celled  sarcoma,  502 

Moist  gangrene,  181 
inflammation,  95 
sterilization,  49 

Moles,  470 

hydatid,  malignant,  617 
pigmented,  470 

Molluscum  fibrosum.  472 

Momberg's    method    of    controlling 
hemorrhage,  342 

Mortification,     179.     See    also   Gan- 
grene. 

Mouth,  actinomycosis,  271 
preparation,  for  operation,  63 

Mucous  cancer,  587 
cysts.  635 
membrane,    lesions,    in    secondary 

syphilis,  314 
sterilization,  63 
transplantation,  90 
ulcers,  211 

Mummification,  179.      See  also  Gan- 
grene. 

Mural  abscess,  151 

Muscles,  gumma,  326 
healing,  77 
regeneration,  77 
syphilis,  325 
transplantation,  90 

Muscular  rigidity  in  inflammation,  117 

Mycophylaxins,  36 

Mycosis,  intestinal,  260 

Mycosozins,  36 

Myelocystoma,  502 

Myelogenous  sarcoma  of  bone,  519, 

;,  j ; ; 

Myeloma,  502,  557 
Myelomatosis,  557 

Myoma,  494 

classification,  494 

diagnosis,  496 

etiology,  494 

pathologic  changes,  497 

prognosis,  497 

sites  of  formation,  495 

structure.    I'.i.'i 

treatmeir 

variation-.  I'.wi 
Myositis.  gummutous,  326 


670 


INDEX 


Myositis,  syphilitic,  325 
Myxolipoma,  462,  482 
Myxoma,  462 

classification,  462 

cysticum,  464 

definition,  462 

diagnosis,  463 

etiology,  462 

pathologic  changes,  464 

prognosis,  464 

sites  of  formation,  462 

structure,  462 

treatment,  464 

variations,  463 
Myxomatous  lipoma,  482 
Myxosarcpma,  512,  517 

diagnosis,  535 


NABOTHIAN  cysts,  635 

Naevus,  483 

Nasal  polyps,  462 

Natural  immunity,  45 

Nausea  and  vomiting  after  anesthesia, 

442 

Neck,  tubercular  lymph-nodes,  281 
Necrosis,  179.     See  also  Gangrene. 
Necrotic  cysts,  647 
Negative  chemotaxis,  35,  36,  40 
Negri  bodies,  251 
Neosalvarsan  in  syphilis,  333 
Nephritis  in  erysipelas,  232 
Nerve-blocking,  435 
Nerves,  healing,  75 

regeneration,  75 

sarcoma,  521 

transplantation,  90 
Nervous  system,  sarcoma,  520,  545 

syphilis,  330 
Neurofibromatosis,  472 
Neuroma,  499 

amputation,  499 

classification,  499 

diagnosis,  500 

etiology,  499 

false,  499 

plexiform,  472 

sites  of  formation,  499 

structure,  499 
Neuroparalytic  ulcer,  208 
Neuropathic  inflammation,  92 
Nevus,  483 
Newborn,  erysipelas,  231 

tetanus,  242 

Nipple,  Paget's  disease,  596 
Nodes,  lymph-,  enlargement,  in  syph- 
ilis, 314 
in  tumors,  446 
involvement,  in  cancer,  601 
sarcoma,  519 
syphilis,  319 
tuberculous,  280 


Nodes,  lymph-,  tuberculous, 

383 

subsequent  course,  282 
treatment,  305 
Parrot's,  322 
Noma,  92 

treatment,  197 
Nose,  elephantiasis,  433 
Novocain  anesthesia,  434 


OBSTETRIC  hand,  243 
Odontoma,  643 

treatment,  644 
Oligemia  in  etiology  of  inflammation, 

96 

Omentum,  sarcoma,  549 
Onychia,  146 
Operative  field,  sterilization,  61 

Grossich's  method,  56,  57,  62 
Opisthotonos  in  tetanus,  240 
Opium  in  inflammation,  137 
Opsonic  index,  41 
Opsonins,  39 
Orchitis,  fibrous,  329 

gummatous,  329 
Orthotonos  in  tetanus,  241 
Oscillation  of  blood-cells,  102 
Ossifluent  abscess,  151 
Osteochondritis,  syphilitic,  322 
Osteoma,  459 

cancellated,  459 

classification,  459 

definition,  459 

diagnosis,  460 

durum,  459 

eburnum,  459 

etiology,  459 

fracture,  459 

ivory,  459 

medullare,  459 

pathologic  changes,  461 

prognosis,  461 

sites  of  formation,  459 

spongiosum,  459 

structure,  459 

subungual,  459 

treatment,  461 

varieties,  460 
Osteomyelitis,    tuberculous,    caseous, 

289 
Osteosarcoma,  502,  512,  518,  540 

diagnosis,  534 
Othematoma,  645 
Ovaries,  adenoma,  569 

sarcoma,  521,  549 


PACHYDERMIA,    acquired,  430. 

also  Elephantiasis. 
Packing  in  hemorrhage,  346 
Paget's  abscess,  153 


See 


INDEX 


671 


Paget'e  disease  of  nipple,  596 
Pain  in  cancer,  600 

in  fracture,  387 

in  gangrene,  183 

in  inflammation,  111-115 

in  sarcoma,  532 

in  syphilis,  315 
of  joints,  324 

in  tumors,  445 

in  wounds,  355 
Painful  ulcer,  207 
Panaris,  146 
Panaritium,  146 
Pancreas,  cysts,  637 

sarcoma,  521,  550 

syphilis,  329 
Pans,  sterili/ation,  65 
Papilloma,  561 

classification,  561 

definition,  561 

intracystic,  564 

soft,  563 

treatment,  564 
Paradoxic  emboli,  405 
Parasitic  cysts,  648 
Parenchymatous  inflammation,  93 
Paronychia,  146 
Parotid  uland,  cysts,  635 

sarcoma,  550 
Parrot's  nodes,  322 
Parulis,  147 

Pasteur  treatment  of  hydrophobia,  256 
Pasteurization,  51 

rating  wounds,  356 
I'i -n't irating  abscess,  151 

wounds,  356 
IVrinephrie  abscess,  151 
Perinephritic  abscess,  151 
Periosteal  bridge,  383 

sarcoma  of  bone,  519 

•  •urn,  sarcoma,  518,  540 
P- TH -tit  is,  syphilitic,  321 
Peril  helioma,  560 
Peritoneum,  tuberculosis  2s.") 

treatment,  306 
Peritonitis,  adhesive,  286 

tubercular,  285 
ascitic  type,  285 

latent    type.    '_N7 
treatlnelH.   :'.(Hi 

ulceraiive  type,  '2^7 
Peril  onxillar  abscess,  152 
PfeitTerV  l.a.-illus,  26 

Pliagedi'llic  Illeer.  209 
treatment,  210 

Pliilagrius'    <>|M-ration   for  aneurysm, 

120 
Plili-hectasia,  424.     See  also  Varicose 

M, 

Phlebitis  in  ervsipel:, 
Phletimasia  MM  dolens,  399 


Pigmented  moles,  470 

sarcoma,  diagnosis,  536 
Plastic  inflammation,  93 
Pleura,  tuberculosis,  283 

treatment,  306 

Pleurisy,  tuberculous,  treatment,  306 
Pleuritis,  tubercular,  283,  284 
Pleurothotonos  in  tetanus,  241 
Plexiform  angioma,  483,  487 

neuroma,  472 

Pneumoni'a  in  erysipelas,  232 
Pointed  condyloma,  562 

treatment,  563 
Pointing  of  abscess,  156 
Poisoned  wounds,  361 

treatment,  369 
Poisoning,    strychnin-,    tetanus  and, 

differentiation,  243 
Polyposis,  adenomatous,  of  intestine, 

569 
Polyps.  462 

nasal,  462 

Port-wine  stain,  483,  486 
Postoperative  fever,  120 
Postpharyngeal  abscess,  152 
Potassium  iodid  in  syphilis,  333 

permanganate,  56 
Pott's  disease,  290 
treatment,  308 
Pressure  in  hemorrhage,  343,  344 

in  inflammation,  129 
Proliferative  inflammation,  95 
Protective  chemic  powers,  36 

powers  of  body  against  bacteria,  34 
Protozoa,  17 
Proud  flesh,  203 
Provisional  callus,  78 
Psammoma,  559 
Pseudarthrosis  in  fracture,  391 
Pseudocapsule  in  sarcoma,  508 
Psoas  abscess,  152 
Puerperal  tetanus,  242 
Pulmonary  anthrax,  260 
Pulse  in  inflammation,  120 

in  septieeinia,  172 
Puncture  in  inflammation,  130 
Punctured  wounds,  356 
Purulent  inflammation,  94 
Pus.  140 

absorption,  143 
symptoms,  144 

blue    141 

••erulean,  141 

d£bris,  141 

definition,  140 

fetid,   140 

iireen.   1  tl 

ichoroiis,  140 

laudable.   140 

on  aspiration,  157 

react  ion,  140 

red,  140 


672 


INDEX 


Pus,  sanious,  140 

solids,  141 

sterile,  141 

tuberculous,  25 

varieties,  140 
Pustule,  malignant,  257.       See  also 

Anthrax. 

Pyelonephritis,  tuberculous,  296 
Pyemia,  175 

etiology,  175 

pathology,  175 

prognosis,  178 

symptoms,  176 

treatment,  178 
Pyemic  abscess,  150 
Pyogenic  membrane,  290 


RABIES,  249.     See  also  Hydrophobia. 
Racial  immunity,  45 
Radium  burns,  treatment,  377 
Ranula,  636 
Ray-fungus,  268 
Raynaud's  gangrene,  188 
Receptacles,  sterilization,  65 
Rectum,  preparation,  for  operation,  63 

sarcoma,  521 

ulcer,  215 

treatment,  217 
Recurrent  dislocations,  396 

erysipelas,  229 
Red  pus,  140 

Redness  in  inflammation,  111 
Regeneration  in  inflammation,  104 

of  muscle,  77 

of  nerves,  75 

of  tendon,  77 
Reinfection,  33 
Renal  tuberculosis,  296 
Repair,  66.     See  also  Healing. 
Residual  abscess,  153 
Resolution  in  inflammation,  107 
Rest  in  inflammation,  126 
Rests,  cell,  452 
Retention  cysts,  633 

of  breast,  637 
Retinal  gliosarcoma,  501 
Retroperitoneal  sarcoma,  550 
Retropharyngeal  abscess,  152 
Reverden's  method  of  skin-grafting, 

81 

dressings,  83,  84 

Rhabdomyoma,  494.    See  also  Myoma. 
Rhexis  in  inflammation,  103 
Rhinophyma,  433 
Ribbert's  classification  of  cancer,  572 

views  of  origin  of  cancer,  573 
Risus  sardonicus  in  tetanus,  240 
Rodent  ulcer,  211 
Round  ulcer  of  stomach,  212 
Round-celled  sarcoma,  502 
Rubor,  110 


SACCULATED  aneurysm,  412 

Sacral  anesthesia,  436 

Saddle  ulcer,  213 

Salivary  glands,  adenoma,  568 

Salvarsan  in  syphilis,  333 

Sanious  pus,  140 

Sapremia,  165 

pathology,  166 

prognosis,  167 

symptoms,  166 

treatment,  167 
Saprogenic  bacteria,  23 
Saprophytic  bacteria,  23 
Sarcoma,  502 

age,  526 

bilateral,  533 

cachexia,  533 

classification,  502 

Coley's  fluid  in,  34,  236,  557 

consistency,  528 

cut-surface  appearance,  552 

deciduocellulare,  617 

definition,  502 

diagnosis,  524 
microscopic,  536 
of  special  forms,  534 

encapsulation,  529 

enlargement,  sudden,  532 

etiology,  504 

fever,  533 

giant-celled,  502 

history,  525 

immobility,  529 

infiltration,  529 

inoperable,  treatment,  556 

melanotic,  511 

metastases,  531 

microscopic  diagnosis,  536 

mixed-celled,  502 

mobility,  529 

mode  and  rate  of  growth,  526 

myelogenous,  of  bone,  519,  543 

of  alimentary  tract,  521,  537 

of  bone,  518,  540 

of  brain,  520,  545 

of  connective  tissue,  517 

of  esophagus,  521 

of  fascia,  517 

of  intestine,  521,  539 

of  kidneys,  545 

of  liver,  521,  547 

of  lungs,  549 

of  lymph-nodes,  519 

of  meninges,  545 

of  nerves,  521 

of  nervous  system,  520,  545 

of  omentum,  549 

of  ovaries,  521,  549 

of  pancreas,  521,  550 

of  parotid  gland,  550 

of  periosteum,  518,  540 

of  rectum,  521 


INDEX 


673 


Sarcoma  of  skin,  516 

idiopathic    multiple    pigmented, 
517 

of  special  organs,  537 

of  spinal  conl,  545 

of  spleen,  521,  550 

of  stomach,  521,  537 

of  testicles,  523,  550 

of  thyroid  eland.  551 

of  uterus,  .vj:{,  551 

pain.  .".:;•_' 

pathologic  changes,  553 

periostea!,  of  bone,  519 

piumented,  diagnosis,  536 

prognosis,  554 

p.-cudocapsule,  508 

ret  [i  (peritoneal,  550 

round-celled,  502 

sites  of  formation,  514 
627 

•pindte-ooDecL  502 

structure,  508 

surface  appearance,  527 

treatment,  555 

urinary  findings,  533 

vascular,  517 

Sardonic  urin  in  tetanus,  240 
Seal),  healing  under,  74 
Scapula,  canes,  289 
Scarification  in  inflammation,  130 
Scirrhous  cancer,  587,  610 
Scrofulous  lymphadenitis,  281 
Sebaceous  cysts,  633 

treatment,  635 
Seed-warts,   561 
Senile  jjannrenc,  184 
Sep~i~.    17.  165 
Septic  infection,  169.      See  also  Sep- 


intoxication,  165.      See  also  Sapre- 

in  in  . 

Septicemia,  169 
anti-eptio  in,   175 
Mood-count.    171 
Mood-pressure,   172 

etiolouy.    Hi'.  I 

in  erysipelas,  232 

pathology.    Ki'.l 

proiMio-N.    17.'! 

pulse  in,   I7'J 

symptom-.   171 

temperature  in.    17'J 

transfusion  of  blood,  175 

treatment.    17:; 

Sepiicopycmia,  \7't.    See  also  Pyemia. 
Se<|iiestration  cysts,  641 

Sequestrum.    I'.tl 

Serous  cavities,  tuberculosis,  'Js:5 

inflammat  \«t 
Serum  treatment  of  anthrax.  261 

of  erysipelas    -•'•<< 

Shirt  -stud  abscess,  153 


Shock,  349 

Crile's  pneumatic  suit  in,  354 

etiology,  349 
exciting,  350 
predisposing,  349 

operation  dunng,  352 

physiology,  351 

prognosis,  352 

symptoms,  352 

treatment,  353 
Sigmoid  colon,  ulcer,  215 

treatment,  217 
Sign,  Halsted's,  in  cancer  of  breast, 

609 
Sinus,  218 

Beck's  bismuth  paste  in,  222,  223 

diagnosis,  220 

etiology,  218 

pathology,  220 

treatment,  222 
Skin,  actinomycosis,  271 

blastomycosis,  334 

reaction  in  cancer,  608 

sarcoma,  516 

idiopathic    multiple    pigmented, 

517 

Skin-cancer,  glandular,  572 
Skin-crafting,  79 

Krause's  method,  87 

E reparation  of  field,  80 
leverdin's  method,  81 

dressings,  83,  84 
Thiersch's  method,  84 
cutting  the  grafts,  85 
dressings.  86 
placing  the  grafts,  84 
Wolfe's  method,  87 
Soft  glioma,  500 
papilloma,  563 

treatment,  564 
tissues,  healing,  66 
warts,  470 

Softening  of  abscess,  155 
Solution,  Harrington's,  53 
Soreness  in  inflammation.  114 

Sperinatocele.   638 

Sphacclus,  179.    See  also  Gangrene. 
Spina  ventosa,  290 
Spinal  column,  caries,  tubercular,  289 
cord,  sarcoma,  545 

syphilis,  330 
Spindle-celled  sarcoma,  502 

Spine,    tllberclll. 

treatment.  :;IIN 
Spiral  fracture. 
Spiroeha-la  pallida.  310 
Spleen,  sarcoma.  521,  550 

syphilis 

S|M»nny  osteoma,  459 
Spores,  19 
S|M>rot  Heliosis,  337 

diagnosis,  338 


674 


INDEX 


Sporotrichosis,  etiology,  337 

pathology,  337 

prognosis,  339 

symptoms,  338 

treatment,  339 
Sporotrichum  Schenckii,  337 
Spreading  traumatic  gangrene,  186 

ulcer,  209 

Squamous-celled  cancer,  572 
Stain,  port-wine,  483,  486 
Staining  bacteria,  19 
Staphylococcus,  23,  24 

epidermidis  albus,  24 

pyogenes  albus,  24 
aureus,  24 
citreus,  40 
Staphylolysin,  24 
Stasis,  102 

Steam  sterilization,  50 
Stenson's  duct,  cysts,  635 
Stercoraceous  abscess,  150 
Stercoral  abscess,  150 
Sterile  pus,  141 
Sterilization,  47 

by  boiling  water,  50 

chemic,  51 

dry,  49 

fractional,  51 

hot-air,  51 

mechanical,  47 

moist,  49 

natural  means,  57 

of  accidental  wounds,  64 

of  apparatus,  65 

of  dressings  and  fabrics,  65 

of  hands,  58 

of  instruments,  64 

of  mucous  membrane,  63 

of  operative  field,  61 

Grossich's  method,  56,  57,  62 

of  pans,  65 

of  receptacles,  65 

steam,  50 

thermal,  49 

Sthenic  inflammation,  93 
Stitch  abscess,  153 
Stitch-hole  abscess,  153 
Stomach,  adenoma,  568,  569 

cancer,  612 

sarcoma,  521,  537 

ulcer,  212 
acute,  214 
chronic,  212 

complications  and  sequels,  214 
treatment,  214 
Streptococcus,  23,  24 

erysipelatus,  23 

pyogenes,  23 
Struma  sarcomatosa,  551 
Strychnin-poisoning,  tetanus  and,  dif- 
ferentiation, 243 
Subdiaphragmatic  abscess,  153 


Sublamin,  54 

Submaxillary  gland,  cysts,  635 

Subphrenic  abscess,  153 

Subungual  osteoma,  459 

Sunburn,  prevention,  376 

Sun's    direct    rays    in   treatment    of 

tuberculosis,  304 
Suppuration,  140 

definition,  140 

Suppurative  inflammation,  94,  107 
Surgical  fever,  aseptic,  120 

wounds,  362 
Suture  of  wounds,  365 
Swelling  in  inflammation,  116 
Symmetric  gangrene,  188 
Sympathetic  inflammation,  92 
Syncope,  local,  188 
Syncytioma  malignum,  616 
Synovitis,  syphilitic,  324 

tuberculous,  288 
Syphilids,  312 

early,  313 

secondary,  313 
Syphilis,  310 

alopecia,  315 

diagnosis,  316 

enlargement  of  lymph-nodes,  314 

eruption,  312 

etiology,  310 

fever,  314 

gumma,  317 

hereditary,  316 

lesions  of  mucous  membrane,  314 

mercury  in,  332 

neosalvarsan  in,  333 

of  abdominal  viscera,  326 

of  bone,  320 
hereditary,  322 

of  brain,  330 

of  bursa,  325 

of  joints,  324 

of  liver,  327 

of  lymph-nodes,  319 

of  lymph-vessels,  319 

of  muscles,  325 

of  nervous  system,  330 

of  pancreas,  329 

of  spinal  cord,  330 

of  spleen,  329 

of  tendon-sheaths,  325 

of  testicles,  329 

of  viscera,  326 

pain,  315 

pathology,  310 

period  of  secondary  incubation,  311 

potassium  iodid  in,  333 

primary  stage,  311 

prognosis,  331 

salvarsan  in,  333 

second  stage,  312 

stages,  311-316 

tertiary,  316 


INDEX 


675 


Syphilis,  third  stage,  316 
"treatment,  331 

ulceration,  318 
Syphilitic  bone  hypertrophy,  321 

caries,  321 

cirrhosis,  327 

dactylitis,  322 

minima.  317 

li-ions,  surgical,  317 

lymphangitis,  319 

lymph-nodes,  319 

myositi^. 

in  erosis,  321 

osteochondritis,  322 

periostitis,  321 

synovitis,  324 

tenosynovitis,  325 

ulcers,  318 
sites  of  predilection,  319 

TABES  mesenterica,  285 

Tcmpcral  ur<-  in  septicemia,  172 

in  tuberculosis,  300 
Tenderness  in  inflammation,  114 
Tendon-sheaths,  syphilis,  325 
Tendons,  healing,  77 

regeneration.  77 

transplantation,  90 
Tenosynovitis,  syphilitic,  325 
Tcratoma,  654 

1  17,  448 
Tertiary  ,-yphili.s,  316 

••les,  sarcoma,  523,  550 

syphilis.  329 

tuberculosis,  2'.»s 
treatment,  307 
Testa,  tuberculin,  300 

Tetannfaeies.  240 

Tetanolysin,  239 
Tetanospasiiiin,  239 
Tetanus.  -j:;7 
acute,  JH 
bacillus  of,  25 

:>ro>pinal    meningitis   and,   dif- 
ferentiation, 244 
chronic,  _'  1  1 
complications,  244 


ernprost  hot  onus,  241 

etiology, 

facial.  •_'}_' 
hea,!.  •_'»•_' 
hydrophobia  ami,  differentiation, 

•JU 

hydro]  ihobicus,  242 
h\>teria  :tinl.  differentiation,  243 
kuopatbic,  _'il 

l.H-.-d.   •_'!•_' 
nascent  ium.  242 
of  newborn,  242 
opi-thotiinos.  240 
orthotonos,  241 


Tetanus,  pathology,  238 

pleurothotonos,  241 

prognosis,  244 

puerperal,  242 

risus  sardonicus,  240 

sardonic  grin,  240 

sequels,  244 

strychnin-poisoning   and,    differen- 
tiation, 243 

symptoms,  239 

tet  any  and,  differentiation,  243 

traumatic,  241 

treatment,  244 
'of  attack,  246 
preventive,  245 

types,  241 
Tetany,  Chvostek's  sign,  243 

Erb's  sign,  243 

tetanus  and,  differentiation,  243 

Trousseau's  sign,  243 
Thecal  abscess,  154 
Thermal  sterilization,  49 
Thiersch's  method  of  skin-grafting,  84 
cutting  the  grafts,  85 
dressings,  86 
placing  grafts,  86 
Thrombosis,  398 

composition,  398 

course,  400 

definition,  806 

diagnosis,  400 

etiology,  398 

in  erysipelas,  238 

prognosis,  402 

symptoms,  399 

treatment,  402 

Thrombotic  hemorrhoids,  399 
Thrombus,  398.    See  also  Thrombosis. 
Thyroglossal  cysts,  641 
Thyroid  gland,  adenoma,  568 

sarcoma,  551  • 

Tissue  formation,  new,  from  inflam- 
mation. 109 
Tongue,  black.  232 
Torsion  in  hemorrhage,  345 
Totipotem  relLs,  655 
Toxins,  32.  :;7 
Transplantation  of  blood-vessels,  90 

of  bone,  88 

of  kidneys,  90 

of  mucou>  membrane,  90 

of  mu.-cli-.  !K) 

of  nerves,  90 

of  tendons,  90 
Traumatic  gangrene,  spreading,  186 

inclusion  cysts,  656 

inflammation,  92 

tetanus,  241 
Tricresol.   ">."> 
Trinmus.  _':;7      See  also  Tetanus. 

Tropical   ab.-cess.    1  Is 

Trousseau's  sign  in  tet  any,  243 


676 


INDEX 


Tuberculin  in  diagnosis  of  tuberculo- 
sis, 300 

in  treatment  of  tuberculosis,  302 
Tuberculosis,  274 

atria  of  infection,  275 
bacillus  of,  25 
heliotherapy,  304 
of  bone,  288 

treatment,  304,  305 
of  cartilage,  288,  291 
of  fascia,  296 
of  joints,  292 

symptoms,  295 

treatment,  305,  306 
of  kidneys,  296 

symptoms,  297 

treatment,  304 
of  larynx,  treatment,  308 
of  peritoneum,  285 

treatment,  306 
of  pleura,  283 

treatment,  306 
of  serous  cavities,  283 
of  spine,  290 

treatment,  308 
of  testicles,  298 

treatment,  307 
pathology,  276 
prognosis,  301 
renal,  296 

sources  of  infection,  274 
sun's  direct  rays,  304 
surgical  treatment,  304-309 
symptoms,  general,  299 
temperature,  300 
tests,  300 
treatment,  301 

general,  302 

non-operative,  308 

specific,  302 

surgical,  3047309 
tuberculin  in  diagnosis,  300 

in  treatment,  302 
urogenital,  ascending,  296 

descending,  296 
Tuberculous  abscess,  279 

treatment,  307 
arthritis,  292 
epiphysitis,  292 
lymph-nodes,  280 

diagnosis,  283 

subsequent  course,  282 

treatment,  305 
osteomyelitis,  caseous,  289 
peritonitis,  285.  See  also  Peritonitis, 

tubercular. 

pleurisy,  treatment,  306 
pleuritis,  283,  284 
pus,  25 

pyelonephritis,  296 
synovitis,  288 
Tufnell's  treatment  of  aneurysm,  419 


Tumors,  110,  443 

benign,  444 

blood-supply,  444 

cachexia,  449 

cell  rests,  452. 

cellular  theory  of  origin,  451 

Cohnheim's  theory  of  origin,  451 

connective-tissue,  452 

cystic,  645 

treatment,  647 

definition,  443 

degeneration,  450 

encapsulation,  445 

epiblastic,  452 
benign,  561 

growth,  rate,  444 

hemorrhage,  449 

heterologous,  452 

homologous,  452 

hypoblastic,  452 
benign,  561 

infiltration,  445 

insane  cells,  451 

lymph-node  enlargement,  446 

malignant,  444 

mesoblastic,  452 

metastasis,  447 

microscopic  differences,  450 

mixed,  452 

mobility,  446 

origin,  451 

cellular  theory,  451 
Cohnheim's  theory,  451 

pain,  445 

rate  of  growth,  444 

recurrence,  449 

ulceration,  448 
Tympanitic  abscess,  154 
Typhoid  bacillus,  25 

carriers,  22 

ULCER,  200 
callous,  204 
chronic,  204 

treatment,  206 
classification,  202 
congested,  207 
diabetic,  of  leg,  201 
duodenal,  212,  214 

treatment,  214 
eating,  211 
elevated,  211 
erethistic,  207 
etiology,  200 
exuberant,  203 
fungous,  203 
gastric,  212 

acute,  214 

chronic,  212 

complications  and  sequels,  214 

treatment,  214 
granulating,  203 


INDEX 


677 


Ulcer,  healing,  203 

healthy,  2<« 
hypertrophic,  203 
in.l-.lent,  204 
irritable,  207 
margin.  202 
Marjolin's,  211 
neuroparah  tic,  208 
of  anus,  215 

treatment,  216 
of  mucous  membrane,  211 
of  rectum,  215 

treatment,  217 
of  sigmoid  colon,  215 

treatment,  217 
of  stomach,  212 

acute,  214 

chronic,  212 

complications  and  sequels,  214 

treatment,  214 
painful,  207 
pathology,  201 
phagedenic.  209 

treatment,  210 
rodent,  211 

round,  of  stomach,  212 
saddle,  213 
shape,  202 
spreading.  209 
syphilitic,  318 

-it.  >  of  predilection,  319 
varicose,  204 
1'lceration  of  cancer,  605 

of  tumors,  448 
I'lccrative  epithelioma,  211 

I'lcils  e\  digest  ione,  212 
I'nion  of  fractures.  77 
I'miniled  fracture,  391 

treatment.  :;'.t2 
l"rachu>.  cysts.  (541 
rrinary  fin. lings  in  sarcoma,  533 
1'rinous  abscess,  154 

•  i  i  t  a  1 1 1 1  b(  •  rculosis,  ascending,  296 
descendinir.  '_".»'> 
1'terine  .-tones,  497 
I't.-rus,  adeimma.   ~>69 
cancer,  till) 
sarcoma.  523,  551 

II 

alltogelioll-.     I.', 
heleroL'.  nous,   43 

Yagina.  preparation,  for  operation,  63 
Valsalva's  treatment  of  aneiirysrn,  419 
Yarices,  424.  See  al--  -  vein*. 

Yaricose  aneury-m,  4  I  1 
ulcer.  20} 
vein-.    121 

complication-.    12.1 
etiology,    421 
JKltholuuy.    121 

prognosis.   12ti 


Varicose  veins,  symptoms,  425 
treatment,  426 

Varix,  aneurysmal,  414 

Vascular  sarcoma,  517 

Veins,  varicose,  424.      See  also  Vari- 
cose veins. 

Venereal  warts,  562 

Verruca  vulgaris,  561 

Viscera,  abdominal,  syphilis,  326 

Vitello-intestinal  cysts,  642 

Vomiting  and  nausea  after  anesthesia, 
442 

von  Recklinghausen's  disease,  472 

Yulvovaginal  glands,  cysts,  637 

WANDERING  erysipelas,  229 
Wardrop's  operation  for  aneurysm,  421 
Warts.  561 

hard,  561 

seed-,  561 

soft,  470 

treatment,  562 

venereal,  562 

Water,  boiling,  sterilization  by,  50 
Weavers'  bottom,  640 
Welch's    bacillus,    gangrene    due    to 

infection  bv,  191 
Whitlow,  146* 

treatment,  164 

Wolfe's  method  of  skin-grafting,  87 
Wool-sorters'  disease,  257.      See  also 

Anthrax. 
Wounds,  355 

accidental,  sterilization,  64 

brush,  357 

characteristics,  355 

classification,  355 

closure,  365 

contused,  356 

gunshot ;  357 
infection,  361 
treatment,  368 

healing,  66.     See  also  Healing. 

incised,  355 

infection,  ii.l.l 

lacerated,  357 

pain 

penetrating,  356 

perforating,  356 

poisoned,  361 
treatment,  369 

punctured,  356 

surgical,  362 

suture. 

treatment,  363 
Wyssokowick/,  law  of,  34 

X  \vi  HKI.VSMA.  -17s* 
Xantlioma.    17s* 

l>urn>.  treatment,  377 
-  in  cancer.  027 
in  fractures,  387 


SAUNDERS'  BOOKS 

on    

Pathology,  Physiology 
Histology,  Embryology 
Bacteriology,  Biology 

W.  B.  SAUNDERS   COMPANY 

WEST  WASHINGTON  SQUARE  PHILADELPHIA 

9,  HENRIETTA  STREET       COVENT  GARDEN,  LONDON 


LITERARY   SUPERIORITY 

*W*HK  excellent  judgment  displayed  in  the  publications  of  the  house 
*  at  the  very  beginning  of  its  career,  and  the  success  of  the  mod- 
ern business  methods  employed  by  it,  at  once  attracted  the  attention 
of  leading  men  in  the  profession,  and  many  of  the  most  prominent 
writers  of  America  offered  their  books  for  publication.  Thus,  there 
were  produced  in  rapid  succession  a  number  of  works  that  imme- 
diately placed  the  house  in  the  front  rank  of  Medical  Publishers. 
One  need  only  cite  such  instances  as  Musser  and  Kelly's  Treatment, 
Keen's  Surgery,  Kelly  and  Xoble's  Gynecology  and  Abdominal  Sur- 
gery, Cabot's  Differential  Diagnosis,  De  Lee's  Obstetrics,  Mumford's 
Surgery,  Cotton's  Dislocations  and  Joint  Fractures,  Crandon  and 
Khrenfried's  Surgical  After-treatment,  Sisson's  Veterinary  Anatomy, 
Anders  and  Boston's  Medical  Diagnosis,  Gant's  Constipation  and  Ob- 
struction, Jordan's  Bacteriology,  and  Kemp  on  Stomach,  Intestines, 
and  Pancreas.  These  books  have  made  f  >r  themselves  places  among 
the  best  works  on  their  respective  sub; 

A    Complete    Catalogue    of   our    Publications   will    be    Sent    upon    Request 


SAUXDERS'  BOOKS  ON 


Mallory's 

Pathologic    Histology 

Pathologic  Histology.  By  FRANK  B.  MALLORY,  M.  D.,  Associate 
Professor  of  Pathology,  Harvard  University  Medical  School.  Octavo 
of  500  pages,  with  375  original  illustrations. 

READY    IN  OCTOBER 

This  new  work  by  Dr.  Mallory  is  destined  to  take  a  place  of  first  rank.  It  is 
complete  and  thorough,  written  in  a  most  clear  and  definite  style.  All  through 
the  entire  work  Dr.  Mallory  has  emphasized  the  practical  side  of  the  subject.  His 
reputation  as  a  careful  worker  gives  this  book  the  stamp  of  authority.  The  illus- 
trations are  all  original  and  stand  out  as  a  striking  feature.  They  are  magnificent. 
As  a  thoroughly  reliable  and  up-to-date  work  on  pathologic  histology  this  new 
book  from  the  pen  of  Dr.  Mallory  is  bound  to  take  the  lead. 

Howell's  Physiology 


A  Text=Book  of  Physiology.  By  WILLIAM  H.  HOWELL,  PH.D., 
M.  D.,  Professor  of  Physiology  in  the  Johns  Hopkins  University,  Balti- 
more, Md.  Octavo  of  1018  pages,  306  illustrations.  Cloth,  $4.00  net. 

THE  NEW  (4th)  EDITION 

Dr.  Howell  has  had  many  years  of  experience  as  a  teacher  of  physiology  in 
several  of  the  leading  medical  schools,  and  is  therefore  exceedingly  well  fitted  to 
write  a  text-book  on  this  subject.  Main  emphasis  has  been  laid  upon  those  facts 
and  views  which  will  be  directly  helpful  in  the  practical  branches  of  medicine.  At 
the  same  time,  however,  sufficient  consideration  has  been  given  to  the  experimen- 
tal side  of  the  science.  The  entire  literature  of  physiology  has  been  thoroughly 
digested  by  Dr.  Howell,  and  the  important  views  and  conclusions  introduced  into 
his  work.  Illustrations  have  been  most  freely  used. 
The  Lancet,  London 

"  This  is  one  of  the  best  recent  text-books  on  physiology,  and  we  warmly  commend  it  to  the 
attention  of  students  who  desire  to  obtain  by  reading  a  general,  all-round,  yet  concise  survey  of 
the  scope,  facts,  theories,  and  speculations  that  make  up  its  subject  matter." 


PATHOLOGY 


Mallory  and  Wright's 
Pathologic  Technique 

Fifth  Edition 

Pathologic  Technique.  A  Practical  Manual  for  Workers  in  Patho- 
logic Histology,  including  Directions  for  the  Performance  of  Autopsies 
and  for  Clinical  Diagnosis  by  Laboratory  Methods.  By  FRANK  B. 
MALLORY,  M.  D.,  Associate  Professor  of  Pathology,  Harvard  Univer- 
sity ;  and  JAMES  H.  WRIGHT,  M.  D.,  Director  of  the  Pathologic  Labora- 
tory, Massachusetts  General  Hospital.  Octavo  of  500  pages,  with  152 
illustrations.  Cloth,  $3.00  net. 

In  revising  the  book  for  the  new  edition  the  authors  have  kept  in  view  the 
needs  of  the  laboratory  worker,  whether  student,  practitioner,  or  pathologist,  for 
a  practical  manual  of  histologic  and  bacteriologic  methods  in  the  study  of  patho- 
logic material.  Many  parts  have  been  rewritten,  many  new  methods  have  been 
added,  and  the  number  of  illustrations  has  been  considerably  increased. 

Boston  Medical  and  Surgical  Journal 

.:;>'•  it-  tir-t  appearance,  has  been  recognized  as  the  standard  guide  in  patho- 
logical technique,  and  has  become  well-nigh  indispensable  to  the  laboratory  worker." 


Eyre's   Bacteriologic   Technic 

Bacteriologic  Technic.  A  Laboratory  Guide  for  the  Medical, 
Dental,  and  Technical  Student.  By  J.  W.  H.  EYRE,  M.  D.,  F.  R.  S. 
Edin.,  Director  of  the  Bacteriologic  Department  of  Guy's  Hospital, 
London.  Octavo  of  520  pages,  219  illustrations.  Cloth,  $3.00  net. 

JUST  READY     NEW   i2d)   EDITION.  REWRITTEN 

Dr.  I>.  re  h.is  subjected  his  work  to  a  most  searching  revision.  Indeed,  so 
thorough  was  his  revision  that  the  entire  book,  enlarged  by  some  150  pages  and 
50  illustrations,  had  to  be  reset  from  cover  to  cover.  He  has  included  all  the 
latest  terhnic  in  every  division  of  the  subject.  His  thoroughness,  his  accuracy,  his 
attention  to  detail  make  his  work  an  important  one.  He  gives  clearly  the  technic 
for  the  ha  tC  examination  '..  milk  and  its  products, 

meats,   etc.      And  he  <;r.  •  technic — methotU  .itu-~ted  by  his  own 

experience.      To  any  one  interested  in  this  line  of  endeavor  the  new  edition  of 
I>r.  Lyre's  work  is  indispensable.      The  illustrations  are  as  practical  as  the  text. 


SAUNDERS'  BOOKS  ON 


McFarland's    Pathology 


A  Text-Book  of  Pathology.  By  JOSEPH  MCFARLAND,  M.  D.,  Pro- 
fessor of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical  College 
of  Philadelphia.  Octavo  of  856  pages,  with  437  illustrations,  many  in 
colors.  Cloth,  $5.00  net;  Half  Morocco,  $6.50  net. 

THE   NEW    (2d)    EDITION 

You  cannot  successfully  treat  disease  unless  you  have  a  practical,  clinical 
knowledge  of  the  pathologic  changes  produced  by  disease.  For  this  purpose  Dr. 
McFarland's  work  is  well  fitted.  It  was  written  with  just  such  an  end  in  view — to 
furnish  a  ready  means  of  acquiring  a  thorough  training  in  the  subject,  a  training 
such  as  would  be  of  daily  help  in  your  practice.  For  this  edition  every  page  has 
been  gone  over  most  carefully,  correcting,  omitting  the  obsolete,  and  adding  the 
new.  Some  sections  have  been  entirely  rewritten.  You  will  find  it  a  book  well 
worth  consulting,  for  it  is  the  work  of  an  authority. 

St.  Paul  Medical  Journal 

"  It  is  safe  to  say  that  there  are  few  who  are  better  qualified  to  give  a  resume  of  the  modern 
views  on  this  subject  than  McFarland.  The  subject-matter  is  thoroughly  up  to  date." 

Boston  Medical  and  Surgical  Journal 

"  It  contains  a  great  mass  of  well-classified  facts.  One  of  the  best  sections  is  that  on  the 
special  pathology  of  the  blood." 


McFarland's 

Biology:  Medical  and  General 

Biology:  Medical  and  General. — By  JOSEPH  MCFARLAND,  M.  D., 
Professor  of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical  Col- 
lege of  Phila.  I2mo,  440  pages,  160  illustrations.  Cloth,  $1.75  net . 

ILLUSTRATED 

This  work  is  both  a  general  and  medical  biology.  The  former  because  it  dis- 
cusses the  peculiar  nature  and  reaciions  of  living  substance  generally;  the  latter 
because  particular  emphasis  is  laid  on  those  subjects  of  special  interest  and  value 
in  the  study  and  practice  of  medicine.  The  illustrations  will  be  found  of  great 
assistance. 

Frederic  P.  Gorham,  A.  M.,  Brown  University. 

"  I  am  greatly  pleased  with  it.  Perhaps  the  highest  praise  which  I  can  give  the  book  is  to 
say  that  it  more  nearly  approaches  the  course  I  am  now  giving  in  general  biology  than  any 
other  work." 


BACTERIOLOGY  AND  HISTOLOGY. 


McFarland's  Pathogenic 
Bacteria    and    Protozoa 

Pathogenic  Bacteria  and  Protozoa.  By  JOSEPH  McFARLAND,  M.D., 
Professor  of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical 
College  of  Philadelphia.  Octavo  of  878  pages,  finely  illustrated. 
Cloth,  £3.50  net. 

NEW  (7th)  EDITION,  ENLARGED 

Dr.  McFarland  has  subjected  his  book  to  a  most  vigorous  revision,  bringing 
this  edition  right  down  to  the  minute.  Important  new  additions  have  increased  it 
in  size  some  180  pages,  By  far  the  most  important  addition  is  the  inclusion  of 
an  entirely  new  section  on  Pathogenic  Protozoa.  This  section  considers  every 
protozoan  pathogenic  to  man  ;  and  in  that  same  clean-cut,  definite  way  that  won 
for  McFarland's  work  a  place  in  the  very  front  of  medical  bacteriologies.  The 
illustrations  are  the  best  the  world  affords,  and  are  beautifully  executed. 

H.  B.  Anderson.  M.  D., 

Professor  of  Pathology  and  Bacteriology,  Trinity  Medical  College,  Toronto. 
"The  book  is  a  satisfactory  one,  and  I  shall  take  pleasure  in  recommending  it  to  the  students 
of  Trinity  College." 

The  Lancet.  London 

"  It  is  excellently  adapted  for  the  medical  students  and  practitioners  for  whom  it  is  avowedly 
written.  .  .  .  The  descriptions  given  are  accurate  and  readable." 

Hill's  Histology  and  Org'anography 

A  Manual  of  Histology  and  Organography.  By  CHARLES  HILL, 
M.  D.,  formerly  Assistant  Professor  of  Histology  and  Embryology, 
Northwestern  University,  Chicago.  I2mo  of  468  pages,  337  illustra- 
tions. Flexible  leather,  £2.00  net. 

THE  NEW  (2d     EDITION 

Dr.  Hill's  work  is  characterized  by  a  completeness  of  discussion  rarely  met  in 
a  book  of  this  size.  1'articular  consideration  is  given  the  mouth  and  teeth. 

Pennsylvania  Medical  Journal 

"  It  is  arranged  in  such  a  manner  as  to  be  easy  of  access  and  comprehension.  To  an/ 
contemplating  the  study  of  histology  and  organography  we  would  commend  this  work." 


SAUArDERS'    BOOKS   ON 


GET  A  •  THE  NEW 

THE  BEST  £\  HI  C  S*  1  C  £1 II  STANDARD 

Illustrated   Dictionary 

New  (6th)  Edition,  Entirely  Reset 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches ;  with  over  100  new  and  elaborate  tables  and  many  handsome 
illustrations.  By  W.  A.  NEWMAN  BORLAND,  M.D.,  Editor  of  "  The 
American  Pocket  Medical  Dictionary."  Large  octavo,  986  pages, 
bound  in  full  flexible  leather.  Price,  $4.50  net ;  with  thumb  index, 
$5.00  net 

IT  DEFINES  ALL  THE  NEW  WORDS— IT  IS  UP  TO  DATE 

Borland's  Dictionary  defines  hundreds  of  the  newest  terms  not  defined  in  any 
other  dictionary — bar  none.  These  new  terms  are  live,  active  words,  taken 
right  from  modern  medical  literature. 

It  gives  the  capitalization  and  pronunciation  of  all  words.  It  makes  a  feature  of 
the  derivation  or  etymology  of  the  words.  In  some  dictionaries  the  etymology 
occupies  only  a  secondary  place,  in  many  cases  no  derivation  being  given  at  all. 
In  ' '  Dorland, ' '  practically  every  word  is  given  its  derivation. 

In  "Dorland"  every  word  has  a  separate  paragraph,  thus  making  it  easy  to 
find  a  word  quickly. 

The  tables  of  arteries,  muscles,  nerves,  veins  etc.,  are  of  the  greatest  help 
in  assembling  anatomic  facts.  In  them  are  classified  for  quick  study  all  the 
necessary  information  about  the  various  structures. 

In  "Dorland"  every  word  is  given  its  definition — a  definition  that  defines 
in  the  fewest  possible  words.  In  some  dictionaries  hundreds  of  words  are  not 
defined  at  all,  referring  the  reader  to  some  other  source  for  the  information  he 
wants  at  once. 

Howard  A.  Kelly,  M.  D.,  Johns  Hopkins  University,  Baltimore 

"Dr.  Borland's  dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  convenient 
size.  No  errors  have  been  found  in  my  use  of  it." 

J.  Collins  Warren,  M.  D.,  LL.D.,  F.R.C.S.  (Hon.),  Harvard  Medical  School 

"  I  regard  it  as  a  valuable  aid  to  my  medical  literary  work.  It  is  very  complete  and  of 
convenient  size  to  handle  comfortably.  I  use  it  in  preference  to  any  other." 


PATHOLOGY. 


Stengel's 
Text-Book  of  Pathology 


Fifth   Edition 


A  Text- Book  of  Pathology.  By  ALFRED  STENGEL,  M.  D.,  Professor 
of  Medicine  in  the  University  of  Pennsylvania.  Octavo  volume  of  979 
pages,  with  400  text-illustrations,  many  in  colors,  and  7  full-page 
colored  plates.  Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  £6.50  net. 

WITH  400  TEXT-CUTS.  MANY  IN  COLORS,  AND  7  COLORED  PLATES 

In  this  work  the  practical  application  of  pathologic  facts  to  clinical  medicine 
is  considered  more  fully  than  is  customary  in  works  on  pathology.  While  the 
subject  of  pathology  is  treated  in  the  broadest  way  consistent  with  the  size  of  the 
book,  an  effort  has  been  made  tc  present  the  subject  from  the  point  of  view  of  the 
clinician.  In  the  second  part  of  the  work  the  pathology  of  individual  organs  and 
tissues  is  treated  systematically  and  quite  fully  under  subheadings  that  clearly 
indicate  the  subject-matter  to  be  found  on  each  page.  In  this  edition  the  section 
dealing  with  ( ieneral  .Pathology  has  been  most  extensively  revised,  several  of  the 
important  chapters  having  been  practically  rewritten.  ' 

The  Lancet,  London 

••  This  volume  is  intended  to  present  the  subject  of  pathology  in  as  practical  a  form  as  pos- 
>il>k-,  and  more  especially  from  the  point  of  view  of  the  '  clinical  pathologist.'  These  objects 
have  been  faithfully  carried  out,  and  a  valuable  text-book  is  the  result.  We  can  most  favor- 
ably recommend  it  to  our  readers  as  a  thoroughly  practical  work  on  clinical  pathology." 


Stiles9   Nutritional   Physiology 

Nutritional  Physiology.  By  PERCY  GOLDIIIU  AIT  STILES,  Assistant 
Professor  of  Physiology  at  Simmons  College,  Boston.  I2mo  of  295 
pages,  illustrated.  Cloth,  £1.25  net. 

JUST   READY 

This  new  work  expresses  the  most  advanced  views  on  this  important  subject. 
It  discusses  in  a  concise  way  the  processes  of  digestion  and  metabolism.  The 
key -word  of  the  book  throughout  is  "  energy  " — its  source  and  its  conservation. 

"  It  is  remarkable  for  the  fineness  of  its  diction  and  for  its  clear  presentation  of  the  sub- 
ject, relieved  here  and  there  by  a  quaintly  humorous  turn  of  phrase  that  is  altogether  delight- 
ful."— Colin  C.  Stewart,  Pk.  £>.,  Dartmoutk  CoUfgt. 


SAUNDERS*    BOOKS   ON 


Jordan's 
General    Bacteriology 

A  Text-Book  of  General  Bacteriology.  By  EDWIN  O.  JORDAN,  PH.D., 
Professor  of  Bacteriology  in  the  University  of  Chicago  and  in  Rush 
Medical  College.  Octavo  of  623  pages,  illustrated.  Cloth,  $3.00  net. 

JUST  READY— NEW  (3d)  EDITION 

Professor  Jordan's  work  embraces  the  entire  field  of  bacteriology,  the  non- 
pathogenic  as  well  as  the  pathogenic  bacteria  being  considered,  giving  greater 
emphasis,  of  course,  to  the  latter.  There  are  extensive  chapters  on  methods  of 
studying  bacteria,  including  staining,  biochemical  tests,  cultures,  etc. ;  on  the 
development  and  composition  of  bacteria  ;  on  enzymes  and  fermentation-products; 
on  the  bacterial  production  of  pigment,  acid  and  alkali  ;  and  on  ptomains  and 
toxins.  Especially  complete  is  the  presentation  of  the  serum  treatment  of  gonor- 
rhea, diphtheria,  dysentery,  and  tetanus.  The  relation  of  bovine  to  human 
tuberculosis  and  the  ocular  tuberculin  reaction  receive  extensive  consideration. 

This  work  will  also  appeal  to  academic  and  scientific  students.  It  contains 
chapters  on  the  bacteriology  of  plants,  milk  and  milk-products,  air,  agriculture, 
water,  food  preservatives,  the  processes  of  leather  tanning,  tobacco  curing,  and 
vinegar  making  ;  the  relation  of  bacteriology  to  household  administration  and  to 
sanitary  engineering,  etc. 

Prof.  Severance  Burrage,  Associate  Professor  of  Sanitary  Science,  Purdue  University. 

"  I  am  much  impressed  with  the  completeness  and  accuracy  of  the  book.  It  certainly 
covers  the  ground  more  completely  than  any  other  American  book  that  I  have  seen." 


Buchanan's 
Veterinary    Bacteriology 

Veterinary  Bacteriology.     By  ROBERT  E.  BUCHANAN,  Ph.D.,  Pro- 
fessor of  Bacteriology  in  the  Iowa  State  College  of  Agriculture  and 
Mechanic  Arts.     Octavo,  5 16  pages,  2 14  illustrations.     Cloth,  $3.00  net. 
THE  BEST  PUBLISHED 

Professor  Buchanan  discusses  thoroughly  all  bacteria  causing  diseases  of  the 
domestic  animals.  He  goes  minutely  into  the  consideration  of  immunity,  opsonic 
index,  reproduction,  sterilization,  antiseptics,  biochemic  tests,  culture-media, 
isolation  of  cultures,  the  manufacture  of  the  various  toxins,  antitoxins,  tuberculins, 
and  vaccines  that  have  proved  of  diagnostic  or  therapeutic  value.  Then,  in  addi- 
tion to  bacteria  and  protozoa  proper,  he  considers  molds,  mildews,  smuts,  rusts, 
toadstools,  puff-balls,  and  the  other  fungi  pathogenic  for  animals. 
B.  F.  Kaupp,  D.  V.  S.,  State  Agricultural  College,  Fort  Collins. 

"  It  is  the  best  in  print  on  the  subject.     What  pleases  me  most  is  that  it  contains  all  the  late 
results  of  research.     It  fills  a  long  felt  want." 


EMBRYOLOGY. 


Heisler's  Embryology 

A  Text-Book  of  Embryology.  By  JOHN  C.  HEISLER,  M.  D.,  Pro- 
fessor of  Anatomy  in  the  Medico-Chirurgicul  College,  Philadelphia. 
Octavo  volume  of  435  pages,  with  212  illustrations,  32  of  them  in 
colors.  Cloth,  $3.00  net. 

THIRD  EDITION— WITH  212  ILLUSTRATIONS.  32  IN  COLORS 

This  edition  represents  all  the  advances  recently  made  in  the  science  of  em- 
bryology. Many  portions  have  been  entirely  rewritten,  and  a  great  deal  of  new 
and  important  matter  added.  A  number  of  new  illustrations  have  also  been  intro- 
duced and  these  will  prove  very  valuable.  Heisler's  Embryology  has  become 
a  standard  work. 

G.  Carl  Huber.  M.  D.. 

Professor  of  Embryology  at  the  Wistar  Institute,  University  of  Pennsylania, 
"  I  find  this  edition  of    'A  Text-Book  of  Embryology,"  by  Dr.  Heisler,  an  improvement 
on  the  former  one.     The  figures  added  increase  greatly  the  value  of  the  work.     I  am  again 
recommending  it  to  our  students." 


Bohm,    Davidoff,  anl 
Huber's   Histology 

A  Text-Book  of  Human  Histology.  Including  Microscopic  Tech- 
nic.  By  DR.  A.  A.  BOHM  and  Dr.  M.  VON  DAVIDOFF,  of  Munich,  and 
G.  CARL  HUBER,  M.  D.,  Professor  of  Embryology  at  the  Wistar  Insti- 
tute, University  of  Pennsylvania.  Handsome  octavo  of  528  pages,  with 
361  beautiful  original  illustrations.  Flexible  cloth,  $3.50  net. 

SECOND  EDITION.  ENLARGED 

The  work  of  Drs.  P.nhm  and  Rividnff  is  well  known  in  the  German  edition, 
and  has  been  considered  one  of  the  most  practically  useful  books  on  the  subject 
of  Human  Histolo-y.  This  second  edition  has  been  in  great  part  rewritten  and 
very  much  enlarged  by  Dr.  Huber,  who  has  also  added  over  one  hundred  original 
illustrations.  Dr.  Huber's  extensive  additions  have  rendered  the  work  the  most 
complete  students'  text-book  on  Histology  in  existence. 

Boston  Medical  and  Surgical  Journal 

"  Is  unquestionably  a  xext-book  of  the  first  rank,  having  been  carefully  written  by  thorough 
masters  of  the  subject,  and  in  certain  directions  it  is  much  superior  to  any  other  histological 
manual." 


lo  SAUNDERS'    BOOKS   ON 

Wells'  Chemical  Pathology 


Chemical  Pathology. — Being  a  Discussion  of  General  Pathology 
from  the  Standpoint  of  the  Chemical  Processes  Involved.  By  H. 
GIDEON  WELLS,  PH.  D.,  M.  D.,  Assistant  Professor  of  Pathology  in  the 
University  of  Chicago.  Octavo  of  549  pages.  Cloth,  $3.25  net 

A  PRACTICAL   BOOK 

Dr.  Wells'  work  is  written  for  the  physician,  for  those  engaged  in  research  in 
pathology  and  physiologic  chemistry,  and  for  the  medical  student.  In  the  intro- 
ductory chapter  are  discussed  the  chemistry  and  physics  of  the  animal  cell,  giving 
the  essential  facts  of  ionization,  diffusion,  osmotic  pressure,  etc.,  and  the  relation 
of  these  facts  to  cellular  activities.  Special  chapters  are  devoted  to  Diabetes  and 
to  Uric-acid  Metabolism  and  Gout. 

Wm.  H.  Welch,  M.  D. 

Professor  of  Pathology,  Johns  Hopkins  University.  , 

"  The  work  fills  a  real  need  in  the  English  literature  of  a  very  important  subject,  and  I 
shall  be  glad  to  recommend  it  to  my  students." 

Ltisk's 
Elements  of  Nutrition 

Elements  of  the  Science  of  Nutrition.  By  GRAHAM  LUSK,  PH.  D., 
Professor  of  Physiology  at  Cornell  Medical  School.  Octavo  volume 
of  302  pages.  Cloth,  $3.00  net 

THE  NEW  (2d)  EDITION— TRANSLATED  INTO  GERMAN 

Prof.  Lusk  presents  the  scientific  foundations  upon  which  rests  our  knowledge 
of  nutrition  and  metabolism,  both  in  health  and  in  disease.  There  are  special 
chapters  on  the  metabolism  of  diabetes  and  fever,  and  on  purin  metabolism. 
The  work  will  also  prove  valuable  to  students  of  animal  dietetics  at  agricultural 
stations. 

Lewellys  F.  Barker,  M.  D. 

Professor  of  the  Principles  and  Practice  of  Medicine,  Johns  Hopkins  University. 
"  I  shall  recommend  it  highly  to  my  students.     It  is  a  comfort  to  have  such  a  discussion 
of  the  subject  in  English." 


HISTOLOGY.  ii 


Datigherty's 
Economic   Zoology 

Economic  Zoology.  By  L.  S.  DAUGHERTY,  M.S.,  Ph.  D.,  Professor 
of  Zoology,  State  Normal  School,  Kirksville,  Mo.,  and  M.  C.  DAUGH- 
ERTY, author  with  Jackson  of  "  Agriculture  Through  the  Laboratory 
and  School  Garden."  Part  I:  Field  and  Laboratory  Guide.  I2mo  of 
237  pages,  interleaved.  Cloth,  $1.25  net.  Part  II:  Principles.  I2mo 
of  406  pages,  illustrated.  Cloth,  $2.00  net 

JUST   READY 


There  is  no  other  book  just  like  this.  Not  only  does  it  give  the  salient  facts 
of  structural  zoology  and  the  development  of  the  various  branches  of  animals,  but 
also  the  natural  history — the  life  and  habits — thus  showing  the  interrelations  of 
structure,  habit,  and  environment.  In  a  word,  it  gives  the  principles  of  zoology 
and  their  actual  application.  The  economic  phase  is  emphasized. 
Part  1 — the  Field  and  Laboratory  Guide — is  designed  for  practical  instruction  in 
the  field  and  laboratory.  To  enhance  its  value  for  this  purpose  blank  pages  arc 
inserted  for  notes. 


DrewV 

Invertebrate  Zoology 

A  Laboratory  Manual  of  Invertebrate  Zoology.  \\\  OILMAN  A. 
I'M.  I)..  \  - -:;int  Director  at  Marine  Biological  laboratory,  Woods 
HoK-.  \I.i  s  With  the  aid  of  Former  and  Present  Membersof  the  Zoological 
Staff  of  Instructors.  i2moof  213  pages.  Cloth,  $1.25  net. 

JUST  READY— NEW  (2dl   EDITION 

The  subject  is  presented  in  a  logical  way.  and  the  type  method  of  study  has 
been  followed,  as  this  method  has  been  the  prevailing  one  for  many  years. 

Prof.  Alluon  A.  Smyth.  Jr..  Virginia  Polytechnic  Institute 

"  I  think  it  is  the  b---t  ;.ii>  .r.itory  manual  of  zoology  I  have  yet  seen.     The  large  number 
of  forms  dealt  with  makes  the  work  applicable  to  almost  any  locality." 


12  SAUNDERS    BOOKS    ON 


Morris'   Cardiac   Pathology 

Studies  in  Cardiac  Pathology.  By  GEORGE  W.  NORRIS,  M.D., 
Associate  in  Medicine  at  the  University  of  Pennsylvania.  Large  octavo 
of  235  pages,  with  85  superb  illustrations.  Cloth,  $5.00  net. 

SUPERB    ILLUSTRATIONS 

The  wide  interest  being  manifested  in  heart  lesions  makes  this  book  particu- 
larly opportune.  The  illustrations  are  superb  and  are  faithful  icproductions  of 
the  specimens  photographed.  Each  illustration  is  accompanied  by  a  detailed 
description ;  besides,  there  is  ample  letter  press  supplementing  the  pictures. 
Considerable  matter  of  a  diagnostic  and  therapeutic  nature  has  been  interwoven. 

Boston  Medical  and  Surgical  Journal 

"The  illustrations  are  arranged  in  such  a  way  as  to  illustrate  all  the  common  and  many  of 
the  rare  cardiac  lesions,  and  the  accompanying  descriptive  text  constitutes  a  fairly  continuous 
didactic  treatise." 


McConnell's   Pathology 

A  Manual  of  Pathology.  By  GUTHRIE  MCCONNELL,  M.D.,  Professor 
of  Bacteriology  and  Pathology  at  Temple  University,  Philadelphia. 
I2mo  of  523  pages,  with  170  illustrations.  Flexible  leather,  $2.50  net. 

NEW  (2d)  EDITION 

Dr.  McConnell  has  discussed  his  subject  with  a  clearness  and  precision  of 
style  that  make  the  work  of  great  assistance  to  both  student  and  practitioner. 
The  illustrations  have  been  introduced  for  their  practical  value. 

New  York  State  Journal  of  Medicine 

"  The  book  treats  the  subject  of  pathology  with  a  thoroughness  lacking  in  many  works  of 
greater  pretension.  The  illustrations — many  of  them  original — are  profuse  and  of  exceptional 
excellence." 


Hektoen  and  Riesman's  Pathology 

AMERICAN  TEXT-BOOK  OF  PATHOLOGY.  Edited  by  LUDVIG  HEK- 
TOEN, M.D.,  Professor  of  Pathology,  Rush  Medical  College,  Chi- 
cago; and  DAVID  RIESMAN,  M.D.,  Professor  of  Clinical  Medicine, 
Philadelphia  Polyclinic.  Octavo  of  1245  Pages>  443  illustra- 
tions, 66  in  colors.  Cloth,  $7.50  net;  Half  Morocco,  $9.00  net. 


HISTOLOGY.  13 


Diirck  anl  Hektoen's 

Special    Pathologic    Histology 

Atlas  and  Epitome  of  Special  Pathologic  Histology.     By  DR.  H. 

DURCK,  of  Munich.  Edited,  with  additions,  by  LUDVIG  HEKTOEN,  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  two  parts. 
Part  I. — Circulatory,  Respiratory,  and  Gastro-intestinal  Tracts.  120 
colored  figures  on  62  plates,  and  158  pages  of  text.  Part  II. — Liver, 
Urinary  and  Sexual  Organs,  Nervous  System,  Skin,  Muscles,  and 
Bones.  123  colored  figures  on  60  plates,  and  192  pages  of  text.  Per 
part  :  Cloth,  $3.00  net.  ///  Saunders"  Hand-Atlas  Series. 

The  great  value  of  these  plates  is  that  they  represent  in  the  exact  colors  the  effect 
of  the  stains,  which  is  of  such  great  importance  for  the  differentiation  of  tissue. 
The  text  portion  of  the  book  is  admirable,  and,  while  brief,  it  is  entirely  satisfac- 
tory in  that  the  leading  facts  are  stated,  and  so  stated  that  the  reader  feels  he  has 
grasped  the  subject  extensively. 

William  H.  Welch.  M.  D.. 

Professor  of  Pathology,  Johns  Hopkins  University,  Baltimore. 

"I  consider  Diirck's  'Atlas  of  Special  Pathologic  Histology,'  edited  by  Hektoen.  a  very 
useful  book  for  students  and  others.  The  plates  are  admirable." 

Sobotta  anl  Huber's 
Human  Histology 

Atlas  and  Epitome  of  Human  Histology.  By  PRIVATDOCENT  DR. 
J.  SOHOI  i  A.  of  Wiirzburg.  Edited,  with  additions,  by  G.  CARL  HUBER, 
M.  D.,  Professor  of  Histology  and  Embryology  in  the  University  of 
Michigan,  Ann  Arbor.  With  214  colored  figures  on  80  plates,  68 
text-illustrations,  and  248  pages  of  text.  Cloth,  $4,50  net.  In 
Saioittcrs'  Hand-Atlas  Series. 

INCLUDING  MICROSCOPIC  ANATOMY 

The  work  combines  an  abun  -.veil-chosen  and  most  accurate  illustra- 

tions, with  a  <  »n<  i-r  tc\t,  and  in  su<  li  a  mannrr  as  to  make  it  both  atlas  and  text- 
book. The  i,rn- .it  majority  of  the  illustrations  were  made  from  .sections  prepared 
from  human  tissues,  and  alwa\s  from  fresh  and  in  e\  <  normal  specimens. 

The  colored  lithographic  plates  have  been  produced  with  the  aid  of  over  thirty  colors. 

Boston  Medical  and  Surgical  Journal 

"  In  color  and  proportion  they  arc  characterized  by  gratifying  accuracy  and  lithographic 
beauty. 


14  SAUNDERS'    BOOKS   ON 

Bosanquet  on  Spirochaetes 

Spirochaetes :  A  Review  of  Recent  Work,  with  Some  Original  Ob- 
servations. By  W.  CECIL  BOSANQUET,  M.D.,  Fellow  of  the  Royal  Col- 
lege of  Physicians,  London.  Octavo  of  1 52  pages,  illustrated.  $2.50  net. 

ILLUSTRATED 

This  is  a  complete  and  authoritative  monograph  on  the  Spirochaetes,  giving 
morphology,  pathogenesis,  classification,  staining,  etc.  Pseudospirochaetes  are 
also  considered,  and  the  entire  text  well  illustrated.  The  high  standing  of  Dr. 
Bosanquet  in  this  field  of  study  makes  this  new  work  particularly  valuable. 


Levy  and  Klemperer's 
Clinical  Bacteriology 

The  Elements  of  Clinical  Bacteriology.  By  DRS.  ERNST  LEVY  and 
FELIX  KLEMPERER,  of  the  University  of  Strasburg.  Translated  and 
edited  by  AUGUSTUS  A.  ESHNER,  M.  D.,  Professor  of  Clinical  Medicine, 
Philadelphia  Polyclinic.  Octavo  volume  of  440  pages,  fully  illustrated. 
Cloth,  $2.50  net. 

S.  Solis-Cohen,  M.  D., 

Professor  of  Clinical  Medicine,  Jefferson  Medical  College,  Philadelphia. 
"  I  consider  it  an  excellent  book.     I  have  recommended  it  in  speaking  to  my  students." 


Lehmann,  Neumann,  arid 
Weaver's  Bacteriology 

Atlas  and  Epitome  of  Bacteriology :  INCLUDING  A  TEXT-BOOK  OF 
SPECIAL  BACTERIOLOGIC  DIAGNOSIS.  By  PROF.  DR.  K.  B.  LEHMANN 
and  DR.  R.  O.  NEUMANN,  of  Wiirzburg.  From  the  Second  Revised  and 
Enlarged  German  Edition.  Edited,  with  additions,  by  G.  H.  WEAVER, 
M.  D.,  Assistant  Professor  of  Pathology  and  Bacteriology,  Rush  Medical 
College,  Chicago.  In  two  parts.  Part  I. — 632  colored  figures  on  69 
lithographic  plates.  Part  II. — 511  pages  of  text,  illustrated.  Per  part: 
Cloth,  $2.50  net.  In  Sounders'  Hand-Atlas  Series. 


PATHOLOGY,  BACTERIOLOGY,  AND   PATHOLOGY  15 

Durck  and  Hektoen's  General  Pathologic  Histology 

A  ii. AS  AND  KFTIOMI <>i  (ii  \TR.\L  Rvrnoi.oi.n  HI>T<>I.O<.Y.  1>\  PR. 
DR.  H.  DURCK,  of  Munich.  Edited,  with  additions,  by  LUDVIG  HEK- 
TOEN,  M.  I).,  Professor  of  Pathology  in  Rush  Medical  College,  Chicago. 
172  colored  figures  on  77  lithographic  plates,  36  text-cuts,  many 
in  colors,  and  353  pages.  Cloth,  $5.00  net.  In  Sounders' Hand-Atlas 
Series. 

American  Text-Book  of  Physiology  second  Edition 

AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  In  two  volumes.  Edited  by 
WILLIAM  H.  HOWELL,  PH.  D.,  M.D.,  Professor  of  Physiology  in  the  Johns 
Hopkins  University,  Baltimore,  Md.  Two  royal  octavos  of  about  600 
pages  each,  illustrated.  Per  volume:  Cloth,  $3.00  net;  Half  Morocco, 
$4.25  net. 

"  The  work  will  stand  as  a  work  of  reference  on  physiology.  To  him  who  desires  to  know 
the  status  of  modern  physiology,  who  expects  to  obtain  suggestions  as  to  further  physio- 
logic inquiry,  we  know  of  none  in  English  which  so  eminently  meets  such  a  demand." — 
The  Medical  \ews. 

Warren's   Pathology   and  Therapeutics        second  Edition 

SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  JOHN  COLLINS  WARREN, 
M.  D.,  LL.D.,  F.  R.  C.  S.  (Hon.),  Professor  of  Surgery,  Harvard  Med- 
ical School.  Octavo,  873  pages,  136  relief  and  lithographic  illustrations, 
33  in  colors.  With  an  Appendix  on  Scientific  Aids  to  Surgical  Diagnosis 
and  a  series  of  articles  on  Regional  Bacteriology.  Cloth,  $5.00  net; 
Half  Morocco,  $6.50  net. 

Gorham's  Bacteriology 

A  LABORATORY  COURSE  IN  BACTERIOLOGY.  For  the  Use  of  Medical, 
Agricultural,  and  Industrial  Students.  By  FREDERIC  P.  GORHAM,  A.  M., 
Asso<  iatc  1'rofosor  of  Biology  in  Brown  University,  Providence,  R.  I., 
etc.  i2mo  of  192  pages,  with  97  illustrations.  Cloth,  $1.25  net. 

11  One  of  the  best  students'  laboratory  guides  to  the  study  of  bacteriology  on  the  mar- 
ket. .  .  .  The  tcchnic  is  thoroughly  modem  and  amply  sufficient  for  all  practical  pur- 
poses."— American  Journal  oj  the  Medical  Sciences. 

Raymond's  Physiology  New  I3dl  Edhion 

li  i\\  I'HY.-KM.M.Y.  By  JOSEPH  H.  RAYMOND,  A.  M.,  M.  D.,  Pro- 
fessor of  Physiology  and  Hygiene,  Long  Island  College  Hospital,  New 
York.  Octavo  of  685  pages,  with  444  illustrations.  Cloth,  $3.50  net. 

"The  book  is  well  gottrn  up  and  well  printed,  and  mny  be  regarded  as  a  trustworthy 
guidt-  for  the  stmlt-nt  and  .1  n-.-tu,  A  .-m-e  for  th<-  p"  •  oner.  The 

illustrations  are  numerous  and  are  well  executed." — The  Lancet,  London. 


16          BACTERIOLOGY,    PHYSIOLOGY,   AND  HISTOLOGY. 

Ball's    Bacteriology  Sixth  Edition,  Revised 

ESSENTIALS  OF  BACTERIOLOGY  :  being  a  concise  and  systematic  intro- 
duction to  the  Study  of  Micro-organisms.  By  M.  V.  BALL,  M.  D.,  Late 
Bacteriologist  to  St.  Agnes'  Hospital,  Philadelphia,  izmo  of  289  pages, 
with  135  illustrations,  some  in  colors.  Cloth,  $1.00  net.  /;/  Saunders1 
Question-  Compend  Series. 

"  The  technic  with  regard  to  media,  staining,  mounting,  and  the  like  is  culled  from  the 
latest  authoritative  works." — The  Medical  Times,  New  York. 

Budgett's  Physiology  New  od)  Edition 

ESSENTIALS  OF  PHYSIOLOGY.  Prepared  especially  for  Students  of  Medi- 
cine, and  arranged  with  questions  following  each  chapter.  By  SIDNEY 
P.  BUDGETT,  M.  D.,  formerly  Professor  of  Physiology,  Washington  Uni- 
versity, St.  Louis.  Revised  by  HAVAN  EMERSON,  M.  D.,  Demonstrator 
of  Physiology,  Columbia  University.  i2mo  volume  of  250  pages,  illus- 
trated. Cloth,  $1.00  net.  Saundcrs1  Question- Compend  Series. 

"He  has  an  excellent  conception  of  his  subject.  .  .  It  is  one  of  the  most  satisfactory 
books  of  this  class" — University  of  Pennsylvania  Medical  Bulletin. 

Leroy's  Histology  New  (4th)  Edition 

ESSENTIALS  OF  HISTOLOGY.  By  Louis  LEROY,  M.  D.,  Professor  of 
Histology  and  Pathology,  Vanderbilt  University,  Nashville,  Tennessee. 
i2mo,  263  pages,  with  92  original  illustrations.  Cloth,  $1.00  net.  In 
Saunders'  Question-  Compend  Series. 

"  The  work  in  its  present  form  stands  as  a  model  of  what  a  student's  aid  should  be  ;  and 
we  unhesitatingly  say  that  the  practitioner  as  well  would  find  a  glance  through  the  book 
of  lasting  benefit." — The  Medical  World,  Philadelphia. 

Barton  and  Wells'  Medical  Thesaurus 

A  THESAURUS  OF  MEDICAL  WORDS  AND  PHRASES.  By  WILFRED  M. 
BARTON,  M.  D.,  Assistant  Professor  of  Materia  Medica  and  Therapeutics, 
and  WALTER  A.  WELLS,  M.D.,  Demonstrator  of  Laryngology,  Georgetown 
University,  Washington,  D.  C.  i2mo,  534  pages.  Flexible  leather, 
$2.50  net;  thumb  indexed,  $3.00  net. 

American  Pocket  Dictionary  New  (7th)  Edition 

DORLAND'S  POCKET  MEDICAL  DICTIONARY.  Edited  Dy  W.  A.  NEW- 
MAN DORLAND,  M.  D.,  Editor  "American  Illustrated  Medical  Dic- 
tionary." Containing  the  pronunciation  and  definition  of  the  principal 
words  used  in  medicine  and  kindred  sciences,  with  64  extensive  tables. 
610  pages.  Flexible  leather,  with  gold  edges,  $1.00  net;  with  patent 
thumb  index,  $1.25  net. 

"I  can  recommend  it  to  our  students  without  reserve." — J.  H.  HOLLAND,  M.  D.,  of 
the  Jefferson  Medical  College,  Philadelphia. 


Date  Due 


PRINTED    IN    U.S.A.  CAT.      NO.      24       161 


A  000  502  528  3 


WO  100 
B915P 
1913 
Bryan,  Worcester  A 

Principles  of  surgery. 


3 


Bryan,  Worcester  A 

Principles  of  surgery. 


WO  100 

B915p 

1913 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


